 Welcome to this new EMCDDA webinar today. I would immediately leave the floor to our director, Alexis Gousdil, for his introduction. Good morning everybody, can you hear me? Yes, we can. Yes, so welcome everybody. I'm very excited to be with you today for this new webinar of EMCDDA. I think it's a very important topic that is crosscutting all areas that are related to drugs, being policy, being responses, being prevention, treatment and so on. And I would say that also cannabis related issues are a perfect illustration of the complexity of drugs issues today. Just a few facts. It's the fact that the concentration of cannabis in THC in the EU has doubled in the last decade. We see the appearance of those CBD products or low THC or products that are called light cannabis. We have seen also the evolution of the knowledge about the medical use of cannabis, but also the appearance of false announcement regarding supposed or pretended properties or therapeutic properties of cannabinoids. And more recently, new products coming essentially first from the states in the US that decided to legalize recreational use of cannabis, such as edibles containing some of them, huge quantities of cannabis. But also the e-liquids. And last year for the first time in February, the early warning system on new psychoactive substances detected through a seizures in Sweden, the first seizure of e-liquids containing 95% of THC. There is also an increasing pressure from cannabis producers towards lawmakers being in countries that have adopted the legislation regarding medical use of cannabinoids that includes provision for the production of cannabis for that purpose. Or pressure on countries that have not yet adopted such a legislation. And in some of the debates it may look sometimes as if market was going to achieve what anti-prohibitionism didn't so far. Some of the defenders of such an option pretending that the miraculous solution would be thanks to the new green gold, a new tax income from member states that desperately need to rebalance their budget, especially following the COVID pandemic. Is it as simple as that or do we miss the broader picture? You understand already with the way I asked the question that for MCDV, the question is certainly more complex and more broad. And the objective of our webinars in general and this webinar in particular is to document that complexity and to reflect about the consequences for policy. So it's not a webinar, it's not a consensus conference, it's not the purpose. And we like and we need to have key speakers who have specific competences. And we don't expect them to agree always and we like to have sometimes some disturbing presentation that gives us food for thought. So don't expect this to be the new official campaign or the new official conclusions or the new official report from MCDV about what you should think or not on cannabis. It's extremely important to use all evidence available to see in what terms and in what conditions there are some needs to maybe continue what we already observe which is maybe a paradigm shift that is progressively coming in Europe. And I want to thank Eva, Marie and Jakob for having accepted to be the guest speakers. And I hope to some extent the ampecheur de pensée en rôle. Those who don't allow the unique thinking or secular thinking, but will bring and share to us, share with us a new fresh scientific evidence. I will join you also for the conclusion of this webinar a bit later. Have a nice webinar. Thank you very much, Alexis. And I would like to introduce Jane Montaigne, the head of Public Health Unit at the MCDA who will be the chairman or the chairperson today. Jane, the floor is yours. Thanks very much, Marica. A real pleasure to be here and sharing this session, this conversation. And maybe just a couple of practical points. The first one that we envisage a series of webinars focusing on cannabis. So this is the first. So welcome to this. It's, in a sense, setting the scene. It's a taster. And in later webinars, we're planning to address different issues, different policy issues, maybe look at markets, product types, other types of responses. So, so if you enjoy today or it or it wet your appetite, please come back because we're, we're planning a season on this topic of cannabis, which we think is really important. And the second point, this is also a teaser for the launch of a new EMCDDA product. It's, it's an update of our European health and social responses guide to responding to drug problems and this time around it's it's a fresh, fresh new product with lots of mini guides. And the first one is launched on the 18th. So not this Monday the Monday after, and it's going to be focusing on health and social responses to cannabis problems. Hence, the link to this webinar. So, so please put the date in your diary. There's even a code QR code of you. If you would like to follow the mailings and the updates on these mini guides. Okay, that's the house business I'm going to now jump in so I'd like to welcome three excellent speakers, and they've been invited to discuss the breadth of their differences. They're covering different areas from epidemiology, clinical issues, social policy so we're hoping to get some kind of different angles in on the topic. I'm from the Institute of clinical psychology and psychotherapy, dressed in university and also University Medical Center Hamburg at Dove. We have ever from the Department of Psychiatry, Ludwig, the Milan University Munich, and we have my husband, who's works at in some National Institute of Health and Medical Research in Paris and she's also on a EMCDDA scientific committee so welcome to our three guests today and our presenters. I'm going to jump straight in now if I could invite Jakob to tackle some of the questions we've got three, three more questions that we're going to ask our presenters at the end. There's going to be an opportunity for you to come with questions to the presenters but I'll kick off. And Jakob I would like to begin by asking you to give us some first thoughts from your perspective on how you would see that the cannabis situation has changed compared with perhaps 10 to 20 years ago. Thank you, Jane for the kind introduction. I want to talk about the results of a study that we've just published two weeks ago to answer your question. And I hope everyone can understand me well I just had some internet problems, like two minutes ago, but I'm great. So maybe you can jump right into the first slide. Perfect. So what we have set out to explore in our paper that was, as I mentioned published two weeks ago is the assessment of how cannabis use and how cannabis harms have developed in the past decade between 2010 and 2019. And what we have collected is, first of all, prevalence of use. As you can see here, the past month use and the near daily use the letters are common indicator for risky cannabis use. And as you can see here, the circles present past month uses as usually the apple line in each plot and then the triangles present the day near daily use. What the colors represent is red color is increasing use and green color is decreasing use, although we were not able to statistically test for trends, meaning that what you can see here is just a comparison of the first and the last point. And if the last point was above the first point, we would speak of increasing use. So generally what we observed in the data that is collected by the EMC-DDA published on their website. Many thanks for that, by the way, and confirmed by the focal points in each country member set and I've seen some of you are also attending the webinar. What we've observed is a general increase in cannabis use. Past month cannabis use has increased from about 3.1 to 3.9%. And as you can see, there's many red lines in the plots. So this means that in nearly every country, we've seen more or less meaningful increases in cannabis use. And what we also observe is that the trend of past month use and near daily use is rather parallel. So the percentages of users that report risky use, meaning near daily use, is rather constant. But what we actually observe and which is quite meaningful, I think, is that the share of users reporting near daily use is quite different in the different countries. We've come up with the figures that I didn't include here, but you can look at the paper. Maybe we can reference it somewhere later. In about half of the countries, 20% or more of the users indicate that they are using cannabis daily or near daily. And as we know, this is a specific risk factor. It increases the risk for health outcomes, for adverse health outcomes. For example, developing a cannabis use disorder. And yeah, this should be giving us some thought on how to think about cannabis use and distribution of use in European countries. There are some countries reporting very high rates of near daily use. For example, Portugal, where 70% of the users reported to be daily or near daily users. So next we have you looked at treatment rates and how they changed over time in Europe. So treatment rates are a common indicator used in various ways and they can be interpreted in various ways. And I'll come to this in a second. First of all, it's important that we've seen an increase in the treatment rates from about 27 to 35 admissions for cannabis use problems per 100,000 adults. So meaning about a 30% increase. In the same time, the number of treatment centers providing data to the EMCDEA has decreased by about 8%. So this gives us a rough idea that actual treatment rates have probably increased in Europe in the past decade. But there's also some important notes to be made here. First of all, the heterogeneity that you can see in the data. With Bulgaria reporting nearly no treatment rates and Ireland reporting very high treatment rates is not reflecting the prevalence of use or the difference in prevalence of use. Because the gaps are not as large. It is related to treatment systems. It is related to reporting standards. It is related to factors that we don't fully understand right now. And it is important to just give you an example for this. Ireland, for example, which had one of the highest treatment rates reported data from 600 centers in 2019. And in Austria, which has doubled the population had only data from 125 centers. It could mean that the centers are just very larger in Austria. But also in Austria, we didn't have any data from low threshold treatment facilities. We didn't have any data from general practitioners or from prisons. So this gives you an idea of how the data quality looks like right now when we come to treatment demand. And this needs to overcome. We have to get some kind of common reporting. But despite all this, it can be assumed that overall cannabis treatment rates have increased. And there's a couple of reasons or explanations for this. For example, rising use, as we've seen in the first slide. Then, of course, cannabis becoming more acceptable to speak of becoming more portrayed in the media. So perhaps people are more willing to admit that they are also having problems. Then what could also be is that people are being referred from the legal system to treatment centers. We don't have any data on this. And it could also just simply be that there is a higher availability of treatment. So all this needs to be followed up. And one important issue that has been mentioned in the literature is that higher THC levels also can be linked to the development of cannabis use disorders and overall problems with cannabis use. And so this could be also an explanation for this, which we actually followed up or looked at in the third slide that I am showing you here. Which is the median THC levels that were identified in herbal cannabis and in resin. And what you can see here for each country are two different lines, again the same colors, green and red. And in the lines there are circles and triangles and the circles are herbal cannabis and the triangles represent resin or hashish. And usually resin contained or is containing more THC than herbal cannabis. This has to do something with the production method. And overall we've seen quite pronounced increases for herbal cannabis, overall a doubling in the past decade and for resin and nearly tripling of the median THC values. As you can see here again, there's a quite large variability between countries. Look at for example, Denmark, which reports consistently very high levels of THC in resin, but we don't have any data for Denmark for herbal cannabis. And then France, this has been reported in the literature before, has seen quite a pronounced increase in resin in the past decade. So why is all this important? THC levels, as I said, is associated with increased risk for cannabis use disorder and may also be associated with high risk for psychosis. What are the reasons for all this? The literature says reports on improved growing methods in both foreign and domestic markets. For resin, this has been observed in Morocco, which is one of the, or appears to be one of the core supplier for hashish in Europe. And but this could also could all not really be tested empirically. And one of the reasons why it is hard to test is we don't really have very reliable data on THC developments in the country. Just to just to briefly note that what you can see here is mostly data reports from police agencies, from law enforcement agencies. And they often do not disclose their methods of analysis. The literature also reports that if you take a sample of cannabis, give it to five different laboratories, you get five different, quite different test results in terms of THC. Again, with lower quality cannabis, especially when it's being grown outdoor, the variation within a plant or within a bulk of THC can be quite large. So not knowing exactly how these data were arrived at is complicating our insights or the degree of the evidence that we have on the trends of THC in Europe. And as you all know, reporting no methods is a no go for most, for research in general. But I mean, this is what we have to live with right now, because this is what we get. There's only one exception or a few exceptions and one of the notable exceptions is the Netherlands, where they do test purchases of cannabis in coffee shops regularly. They report the methodology and surprisingly they didn't really see notable increases in recent years in THC. Just to say you're beginning on the second question. So maybe I could just move on a little bit to then the second. Yeah, I was done with it anyway. No, that was great. I was hearing you were beginning to move. So just to share with everybody what we were then interested in hearing. So after sort of looking at the 10 to 20 years and I've heard rising use that some very variability. There's some increases in treatment demand, but again, it's a bit complex and we need to unpick a little bit what the different types of treatment systems is and also rising THC levels which could be implicated in those harms of these and also in your other work and experience. What do you see the pressing most pressing challenges right now from again from your perspective and and in your view is the current cannabis policy debate having any impact in terms of these pressing challenges. Yeah, the all the red lines that you've seen in my slides, just red lines for now that have to be interpreted and that have to be most importantly translated into health harms. Are we actually seeing an increase in health harms in European countries or not. This is the question that we have to move on with research right now. So I think that's quite important to really focus on what does this mean really for users and for the public. And to for this we need more reliable data. I'm coming actually more from the alcohol epidemiological field where we have much better data owing in part to legal markets, but also because research was not made so complicated for a long time. So that's quite important to note and as with regards to your second part of the question is the policy debate helpful. I would say it's both helpful and not helpful. It's helpful in the sense that it's pointing out that it's not only health harms related to cannabis but also social harms due to persecution. For example, in Germany we have seen rising numbers of persecutions in the past decade or two. And of course, this are just additional harms to users that are not necessarily linked to health, but they are existent. And it's also important to really focus on these, but they are not helpful these discussions because they are often only focusing on the social harms and the question legalize it or not. But we need to broaden up, we need to leave the room for health aspects of cannabis use. Just an example, a recent survey among North American cannabis users, four out of 10 users did not believe that cannabis can result in a dependence. And I think this is where we can see a gap between the evidence that we've collected already and the current discussions. And I think this gap needs to be closed. Great. Thank you, Jacob, and I think that was a good leading to our next speaker actually in terms of the harms. Perhaps I could now invite Eva, Eva Hoch to have a go at answering our first question and from her perspective on how cannabis situations changed in the last 10 to 20 years. Hi, everybody. Maybe a sentence about my person. I'm a cannabis researcher and I'm also a psychologist, a clinician, and I have special focus on cannabis use disorders. And I do a lot of trainings in the treatment of cannabis use disorders, not only in Germany, but also in neighboring countries. So I have strong focus and few on scientific evidence, but also the patient and treatment settings and treatment systems. And that's my focus today on your question. Next slide, please. And what cannot what I can say from my perspective, that in the past 10, 20 years, the picture has become much more complex. As said before, we have potent products on the market, and we have an increasing diversity in products. We have multiple formulation, loads of administrations, and especially we have larger variability in edibles, beverage not so far in Europe, but in the Americas, vaping devices and dabbing that's not so common in Europe so far. We have a large and growing CBD market. So we have in all European countries, we have retailers, we have internet shops, and there is a lot of marketing of the health benefits of these products, and the risks are not so clear. The CBD is largely under study. We have very little studies so far. Some of them, they indicate health benefit, for example, in people with psychosis, but in for other mental and physical diseases, we clearly lack information. For example, can CBD be helpful in people with a cannabis use disorder and other addictions, and we only have a handful of studies and only one of these studies has been published before. And also the legal status of these products is unclear. Is it a medicine or a novel food? So there's much uncertainty so far. And of course we have cannabis as medicine. There is an increasing demand in Europe. There is proven benefit for some health conditions, for example chronic pain. But again, we have a large knowledge gap in other mental and physical disorders, and we really also have conflicting data because the basis is so small. And it's very difficult to come up with a recommendation who should be treated with cannabis medicine. For example, someone with a cannabis use disorders. Is THC, for example, appropriate medicine or CBD? We don't know so far, but that's a novel approach. Next slide, please. So what I can see in Germany and other European countries, we have a shift in the perception of cannabis. Is it something good? Or is it something bad? Or can it be both? There is a heated debate. Next slide. And when it comes to the treatment of cannabis use disorders, we see it's the number one drug in children and adolescent when it comes to drug related hospital emergency presentations. It's mentioned, I think that the third most drug in those older than 19 years. We have a European report published in 2020 showing this data. And as mentioned before, treatment demand for cannabis has increased in the past two decades, and it seems to stabilize at the moment at a historically high level. But it's very little. We actually know about these people who come to treatment. We know in outpatient treatment settings over 80% are males, 50% of those are daily users. We know that they start cannabis use at the age of 17, and they come to treatment at the age of 25. So you can see here there is a large gap. What happens in between, between 17 and 25? We don't know. And we have very little information about these people who come to treatment and especially we have very little information about those who don't want to come to treatment. And outpatient setting is the one thing, but there are other treatment settings, for example, psychiatric hospitals as I'm working in. So we know when I can tell you from my perspective that cannabis has become very common and popular among patients with mental disorders. And in our group of young psychotic patients with the first episode of psychosis. All of them are using cannabis and they start at an early age and as we just found out in a survey, they prefer a strong cannabis products, which may not be so good for the prognosis of the psychosis. So we really miss information on a broader level on a European level about treatment seekers. And we know a little bit what is effective, mostly brief or short term interventions up to 12 sessions. And these interventions which are applied in Europe, they are either cannabis specific or they are general substance use treatments and they both work and there seems to be preference in some European countries for either cannabis specific approaches or general approaches. And usually these programs, they combine motivation enhancement and cognitive behavior therapy. Next slide please. And what I can see from my perspective that there is a shift in treatment paradigm. We move from an abstinence paradigm to control use or reduced use or harm reduction that doesn't apply to all European countries and all settings. And the positive side to this is that more groups of patients can be reached. But the negative side is that there is confusion in treatment settings and teams about the most adequate treatment goal to a patient. Yeah, who should become abstinent or who should control or reduce the use. It's not so clear. And we do have a lot of challenges, especially how can we address and reach the young and problematic cannabis users. They are often not interested in change or in treatment, and it's difficult to reach them and to motivate them for change. The next thing is, how can we increase knowledge about cannabis use disorders for example in schools. They are often not recognized. And yeah, often in treatment settings. There is a need for training. And often there is no specific training available and no money for this. And what I can also observe in the past decade, there is little diversity in the existing treatment approaches. Between 2004 and 2007, some cannabis specific programs have been developed and tested and implemented in Europe, but since then very little happened, and we still have high relapse rates. We have people with comorbidity and we don't have approaches for these special groups of patients. So we have very few novel approaches and from my perspective, e-health is not established. That would possibly help to reach new groups of people. And also we do not have effective psychopharmacotherapy. So just as I said before, is CBD something interesting? We don't really know so far. So I observed in the last 10 weeks, little political will and effort to give money to move forward in a good direction. Thanks. Thank you, Eva. That was really, really stimulating and you've moved on and answered very much part of the second question, the challenges, which I think you've explained really clearly to us. Just if you had any other follow-up thoughts on the current policy debate itself, having a particular impact in terms of the challenges, particularly you were talking about young people treatment. Yeah, cannabis is a top issue in the media, in the public, on the internet. It's there, yeah, and it will stay. We have to face cannabis, yeah, and we have to give it the attention I think it needs. We know a little bit or not a little bit. We have knowledge about those at risk. It's clear that young people at early age or daily cannabis users or those who are vulnerable for mental disorders or also women, breastfeeding or pregnant women. We do know that there are very vulnerable groups and we should be clear and have clear messages and we really need to start to do more prevention right now in schools but also beyond. And I think we should use this current debate to be more open to talk to each other and to establish more political will to see both sides of the medal. So there is a benefit from cannabis or medicinal benefit and there are risks. And so it's not, we have two sides of the medal and we have to recognize that they do exist. Great. Thanks. Thanks very much Eva and we'll come back to you for the third question in a moment. And I will just take a quick prerogative to flag two really important issues we've got publications on, which is the low THC products and the medicinal use of cannabis products which we're going to be updating so if anyone's interested in a bit more we've got publications on this. And maybe I could invite Marie to to share her thoughts on how cannabis situation has changed compared with 1020 years ago and add a little bit more food to our table on this discussion. Thank you. Thanks again. So first, I would like to thank you, Eugene, Alexi and Marika for inviting me to this webinar and I also need to give some words about who I am. So I am a sociologist and a political scientist, and I'm an expert in drug policy with the focus of harm reduction. So that's why I will also speak from another perspective that is complementary to my colleagues. So perhaps to I will begin as to answer to your first question. And what is important for me from my perspective is also to go beyond the trends of prevalence that are very important but I personally think that the way we consider now cannabis and harms as considerably changed this last year, this 20 last years due to due to a growing body of scientific evidence in different areas of research, including neuroscience, public health and sociology. Even if, as Eva just said, some topics related to cannabis are still controversial in the scientific literature. What is important for me to say is also that compared to alcohol, the social perception of cannabis have been for a long time driven by moral perceptions due to the illegal status of cannabis in main countries, compared to the legal status of cannabis. As a slide one please. So I wanted also to highlight this publication of David Nutt in the Lancet in 2010. And because this publication introduced a new way to consider the harms of cannabis use by differentiating individual and collective harms. First and secondly by highlighting that legal drugs, such as alcohol and tobacco also need to be considered on the same level as cannabis by setting ideology aside. And by studying all drugs with the scientific lens, it appears that legal drugs can also cause individual and collective harms as illegal drugs are. And it is interesting to note on these graphs from David Nutt's Lancet articles that cannabis causes proportionally less collective harms compared to alcohol for example, because alcohol is involved in a lot of domestic violence events for example, and that is an area that is totally neglected. So in recent years, several scientific publication also showed that harms from drugs are not only linked to the pharmacological power of substances, or to generate differences between people. And I think that it's also a major change since it's these last 20 years. So harms are also caused by a complex environment of risk. That is, this concept of environment of risk is a framework that has been introduced by the sociologist team roads in a publication in International Journal of Drug Policy in 2002, and this environment of risk can also be applied to cannabis and it includes structural factors that may increase the harms from cannabis, including the stigma of drug use. The fact that some people live in deprived environment and also the persecution of people who use drugs. And that is also an important topic. There is also another moral misperception that has been broken by scientific evidence. And this is the distinction between art and soft drugs. So cannabis has for a long time been considered as a soft drugs, but due thanks to scientific literature, cannabis cannot be considered anymore as a soft drug. But it is also clearly demonstrated that even if the dependence with cannabis exists, the transition to dependence can be less important with cannabis compared to other drugs. For example, a paper that has been published by NIDA in the Journal of Drugs and Alcohol Dependence in 2011 showed that the cumulative probability estimate of transition to dependence was 68% for nicotine users, 23% for alcohol users, 21% for cocaine users and 9% for cannabis users. And to conclude on this first point, I also think that scientific evidence also helps us to identify better which subgroups are more at risk with cannabis use and where the interventions to reduce harm sling to cannabis use need to be focused. Neuroscience help us to understand that precocity of cannabis use among adolescents is one of the main risks that needs to be addressed by improving the prevention responses. And public health also showed that early cannabis initiation use among adolescents before 16 years old is associated with low school attainment, especially for young women. I contributed personally to demonstrate the social harm linked to cannabis use in a paper that we published in International Journal of Epidemiology in 2017 with a colleague, Maria Mercure, who is working also at INSEAM. So, Jane, that's why I want to give you a but for this first question. Thank you very much. That's great. Second question then. What would you say, and you've begun to, I think you have begun to answer in what you said, but maybe you'd like to develop a little bit the most pressing challenges right now. And the current cannabis policy debate, how's it having an impact? So, to answer to your second question, I think that one of the more pressing challenge now is to address the topic of social inequalities in the area of cannabis use, but in the area of drug use more globally. That's very difficult for me to speak only about cannabis without having a more broader perspective with all the drugs, and especially with the topic of social inequalities. So, in this topic, scientific literature has also largely shown that socioeconomic inequalities, including poverty, limited education and marginalization may increase the risk of developing drug use disorders for cannabis and for also other drugs. So, can you show the second slide please? So at the international level, this graph that is from Wilkinson and Pickett illustrates perfectly the weight of social inequalities in drug use. But cannabis use harms need also to be understood in their complexity by distinguishing recreational or problematic use regarding social inequalities. For example, in my country, France, social epidemiological surveys conducted by the French UMCDDA focal point, UFDT, showed that adolescents who are from high and middle class declared higher trends of cannabis use. But at the same time, adolescents from lower social class declared more problematic use of cannabis. And we can explain that by two causes. The first one is that these adolescents from lower social class live in socially and family deprived environments, but a second reason that can explain that there are more problematic use of cannabis is because these adolescents have less access to prevention and less access to treatment due to a lack of social support and lack of adequate networks connected to care. And it seems to me that this topic of social inequality is a very urgent topic that needs to be addressed. Indeed, there is another most pressing challenge that is that we need to address, which is the stigma linked to cannabis use and that can impede, that may impede a good access to treatment for the most vulnerable group of users. Vulnerable and marginalized groups of users may face barriers to getting treatment services due to discrimination and stigma. And now it seems to me that prevention interventions needs to seriously address this challenge of reducing social inequalities by allowing people and communities to protect themselves from a problematic use of cannabis. Drug policies are effective only if they really act on improving the social environment in which people live. As it is shown in this graphic representation from a UNIDC report, can you show please the slide three. So on this graphic representation, you can see which are the protected favour that can prevent people from drug use, including cannabis use. So we have a very, very important body of scientific literature that shows that promoting safe neighbourhoods, promoting physical safety and social inclusion, promoting quality of school environments, promoting a better access to health care and improving health and neurological skills, including coping skills and emotional regulation and favouring caregiver involvement may decrease a lot the trends of cannabis use. And that's why I think that it is very important to when we speak about cannabis to also speak about social inequalities and how improving lives of people in general may have a positive impact in decreasing the use of cannabis use and especially decreasing the arms related to cannabis. Thanks, Marie. That's great. I'm really, really appreciate that input and bringing in the absolutely fundamental aspects of the social and environmental issues into the discussion. Okay, panellists. I'm going to ask now I'm going to go back to Jacob and then ask each each panellist in turn just to have a go at summarising in two to three minutes, some thoughts for the future because we've we've had lots of lots of inputs to suggest we've got a new situation and we need to be thinking differently. Maybe our old models the walls are crumbling and we need it's time for a paradigm shift in the way we think about cannabis so I'm going to ask each presenter in turn starting back with the Jacob to have a go at telling us what you think we need to do differently and how we might need to respond in different ways to be effective with the new challenges in the cannabis area and what might a new responses paradigm look like. Let me put you on the spot says just hear your thoughts. Yeah, thank you. I think one of the most pressing issues is to really focus on the harms that are currently arising. The complexity of the harms have been described by all of us, I think different dimensions of the complexity, perhaps. But if we can agree that harms are existent and the harms need to be addressed. We need to think about a strategy how to address and mitigate these harms. And I think one of the issues that will arise first, or one of the first steps that need to be tackled is to decriminalize use because this is just a huge burden on users that have harms that is just not justified and we've seen many examples where this worked. And second, we need a good understanding on the health harms. I've outlined a few limitations and have also broaden aspects on new markets, new products that we do not understand well right now. And especially the contribution of, for example, synthetic cannabinoids to treatment presentations is just, we don't know anything about this right now really. We don't know why people die from using cannabinoids, synthetic cannabinoids. So all of this really needs to be addressed and we need a good understanding of the harms and then develop a regulation model that really accounts for all the different complexity. And I'm really happy that Marie, she addressed the deputation issue in this and what she mentioned that people with deprived backgrounds are more likely to use cannabis more risky, same applies to alcohol, which I study a lot. And we need to understand this and a regulation model needs to understand that availability cannot be higher in more deprived neighborhoods, which we see in North America and a lot of US states and Canada. So this is something that we need to understand, where we need to really think about in a broader perspective, and then act accordingly to really act on that goal to mitigate the harms. And yeah, I think that would be a really paradigm shift. Thank you very much, harm-focused model, Eva, over to you. Yeah, I think I'm supporting Jakob's ideas and thoughts. First, I think risks of cannabis are differently pronounced that every user has the same risk, but we need to know who is at risk. So we need better health monitoring, we need different health indicators, we need the resources at national and regional levels to do this. We have very poor assessment of cannabis use so far, we don't have a gold standard. We compare sometimes apples to other fruit. And so we really think we really should improve the way we assess cannabis use and cannabis related harms. And I also think we need better interventions of prevention and treatment, we need new approaches. And it's very important that cannabis researchers are supported, that barriers are taken away from cannabis research. It's sometimes very difficult, we have high regulations. We often do not have the political will to do our research and as I know from colleagues around the globe, we really need money to do our work. It's not enough to do systematic reviews, we have to do original work. And my second thought is, it's not time to sit and wait, it's time to take action and it's really essential to join forces and to bring together the different key players. And it's also a good idea than when politics listens to science, but that's not enough. We have to come together, politics, scientists, public health patients and to give advice to policymakers and that's what I stand for. Thank you. Thanks very much, so some new health indicators improve the assessment and actually working together more in a multidisciplinary way to advise and get some policy development and change. Thank you, I think my teacher just went for a minute, hope I'm back. And finally, could I bring in Marie back into the debate please to give us your thoughts on what we need to do differently. What new responses paradigm might look like. I think that I think that we only share the same concern about the risk related to cannabis so this risk exists. It's more important in some subgroups, but what we also need to have in mind is that the criminalization of cannabis and the persecution of people who use cannabis is not working. So that's why now we can see that at the international level there is a growing movement of new alternatives to criminalization of produce. That includes the legalization of cannabis in some countries since 2013 or the decriminalization of all of drugs that Portugal since about choose 20 years ago. And that's very complex to know what are the best models. And as Alexi said, in introduction, we that's not possible to say that cannabis legalization will be a magic bullet. What we know now from the legalization, the cannabis legalization is that it doesn't increase the level of use among adolescents. And that's something that is very important. Because one of the groups that is more at risk for cannabis use are the adolescent and there are some very recent publications, especially one publication in JAMA Network, perhaps two or three days ago, showed that in the US, in the United States, they did a study about the last 20 years of use among adolescents and they found that there was a little decrease of cannabis use among adolescents. That's the same also in Canada. I discussed a lot with my Canadian colleague about the effect and the impact of legalization and the fear that legalization can lead to an increase among adolescents seems not to work because in Canada, they also didn't have any increase among adolescents. So that's something that is important to have in mind. And at the opposite, I can speak about my country because France has one of the most repressive policy towards cannabis in Europe and we have the highest level of cannabis use among adolescents. And as Jacob just showed before, we have also very, very high increase in THC levels in cannabis in France. What we know now is that when we want to criminalize, the governments that have decided to criminalize cannabis have not good results with this type of policy, so that's why we need to have some alternatives. But with the legalization aspect, I think that it is very, very important to have in mind that we need to always prioritize a public health perspective. And my fear is that now with the legalization of cannabis, some countries think that they will have a lot of economical benefits with cannabis legalization. And these economical benefits can also lead to what we call a big canna and that can be compared with the big pharma that the United States have to face with the opiates markets. So that's why that's a very complex question. But personally, I think that now the scientific literature agrees that criminalization is not a good solution. And that we need to think about alternatives. That's great. Thank you very much, Maureen. Thanks to everybody for those challenging and insightful answers. And I'm going to move now into opening up the floor to questions, so if everybody can be prepared and I will start while Marika's having a little look through the chat and also our presenters can have a look through the chat too to see if there's things that they want to pick out. But I just want to recognize there's been lots of illusion and comments about the North America, so we say the States and Canada and it's not very surprising. Just just now Marie you were talking about big canna and Alexi mentioned green gold. Lots going on there and we're kind of watching. If you like, I think countries are watching and we see different models of health perhaps the health centered Canadian model and the more economic models we're seeing in the US. I'm wondering implications for responses. So it's kind of one of my questions if we following a little bit what we see not just not just harms but harms is part of it but also the interventions that may be being developed in these countries. I'm wondering, I mean I'm aware perhaps of Canada and some some interesting harm reduction guidelines for example Fisher and I'll have been working on for some years. I know less about treatment and I'm wondering again is have there been any interesting developments in cannabis treatment maybe ever I can throw that one at you to start with and maybe our other panelists might want to come in but any thoughts on this in Canada specifically or in general. I'm just thinking in the US is a little bit ahead and opening up and are we seeing, are we seeing parallel developments in in the in the clinical side with the open markets. As far as I know, the latest advancement in the treatment of cannabis uses orders is the application of cannabis based medicine so I think that's a new trend. It's coming from the United States and cannabis medicine is also applied to other addictions. So, for example, opioid dependence withdrawal of opioids, cocaine dependence, and there's a small trial of tobacco addiction, but I think in general. Not so much has happened and what we can see in the United States that treatment rates are decreasing that people who don't get treatment instead of punishment as in more recent in the past. So, that could be something that's happening also in Europe that cannabis is not considered as a problematic drug and there is more acceptance of cannabis and less pressure for people to come to treatment. So that may be a future trend that that people don't come to treatment anymore or that there are people at risk and we don't get in touch with them. Or it could be that we can get in touch with them much better because there is less stigma and people are more willing to come. So, I really don't know what's going to happen. But I think that cannabis stigma is a high barrier to come to treatment and many of my patients, they ask me, Dr. Hoek, is it really necessary that you tell the health insurance company that I have a cannabis use problem. Can't you say it's a depression? So, you know, there are many consequences from this disorder. But when it comes to treatment, I don't see so much development, not psychosocial treatment. Okay, thanks. I mean, would Jacob or Marie like to come in on the cannabis harm reduction, Si? Marie? Yes, personally, I think that the Canadian model is probably more interesting for Europe compared to the US model because what is interesting with the Canadian model is that they have this legalization of cannabis but they try to do this with an involvement of the state that is more important. So, they try to regulate more the cannabis legalization and it will probably prevent from the risk of the big canna that I mentioned before. And what is also very interesting in Canada is that as Canada as in general a less proactive model for drug policies and is more involved in harm reduction, they also try to develop a lot of intervention to prevent cannabis. And these interventions are especially psychosocial intervention that try to improve the self-esteem of young people to allow them to resist to the influence of peers if they don't want to use cannabis. And all these psychosocial interventions that can increase self-esteem as an area of interventions that needs to be developed and that's the way Canada has chosen. Thank you. Okay, Marika, maybe I could bring you in and you've been following the chat quite closely and perhaps. Yes, there are some questions on how you measure the percentage and the average percentage of TAC in the cannabis that is consumed. These are I think mainly for YACO, I don't know if you want to gather them. Overall, then there are comments on the paper by NAT discussing if there were cannabis trends at the time, if it is updated enough, etc. And so we can start with these two, because there are many questions. We want to be able to take them over, but probably we can comment on these two mains. Okay, so the first one was for Jacob. Jacob, can you talk? Yeah, thanks. So measuring THC in cannabis is actually not too complicated. There are a few standard methods to do this. The problem really is do we get a representative sample of cannabis that is actually being used by the people in the target population. So there's been a couple of pilot studies where people asked users to provide joints to the research team. And then the research team actually analyzed the joints they picked out of the cannabis or the resin from the joints separated the tobacco from the rest, and then they analyzed the samples. So that works, but for example, a pilot or very well cited study in Spain, critics of mine done this, found very, very low, surprisingly low levels of THC in those samples. So approaches like this, I think very meaningful in understanding what is going on in the markets and also to have a benchmark separate from the law enforcement agencies, something that is very native to research to have independent assessments of the same phenomena to really understand the picture as a whole. And, but to really connect this to a previous topic that we've just touched is getting these kind of studies done is incredibly complicated. We've tried to do this in Germany. No chance. There's no one giving us money for this. And there's no one that actually could guarantee that we are not being put into prison for this because taking joints from users just to take them, give it to the pharmacist, get it analyzed there because pharmacists can do this. Because we are just taking them and as a middleman, we could be thrown into prison. So this is the type of barrier that we are facing right now in this kind in this field and this research field and similar things going on with synthetic cannabinoids. We have a laboratory that do routine testing of synthetic cannabinoids in blood and urine test samples. And we have the data we can analyze the data. We can do this, but no one's giving us money for this. We try to write grants and yeah, it's very complicated. So you see, there's lots of efforts going on to really understand this better but barriers are high. Maybe. My add something is the same to CBD content in cannabis products. It would be so important to know the ratio. Yeah, but we don't really have the information on a regional level. And also we know from the cannabis users that there are other ingredients that shouldn't be in the cannabis products, hairspray and other constituents you don't want to use. So it's difficult as a researcher. Remaining on the risks, there is one question asking how can you disentangle the risks linked to the contemporary consume of tobacco with the risks linked to the increased THC quite briefly because we want also to move to other questions asked. Anybody want to have a go at that one the risks linked to tobacco to the risks linked to THC or do we just say it's a very good question and we No, it is. Yeah, I can just briefly are so it's incredibly difficult, especially in countries from an epidemiological point of view in countries in Europe, it's incredibly difficult because about 90% of the users use both cannabis and tobacco. So disentangling the two phenomena and the two risk factors is incredibly difficult just out of numerical numbers. You have you need really large sample sizes to get the sufficient number of people who only use cannabis. This is different in the US and Canada where less than 20% actually use tobacco and cannabis or cannabis combined with tobacco. So again, we have to rely on North American research and fortunately, creating colleagues actually do get some money to do this, but only European data will be very, very difficult to do this. Thanks. I'd really like to get your second question, Marika, because I think it's really interesting that the one about the David Knutt study. It was 10, you know, it was 2010. Would it look different if it was done now with what we're saying about the changes. Maybe I can bring Marie back in as she presented the that slide what do you think Marie would be any. Would it look different with the changes in the cannabis market and the related. I don't think so because recently David Knutt updated in other publications this trend and alcohol is still at the top level. And that's also the case with tobacco but I think that it's important not to misunderstand what David Knutt want to to demonstrate. It doesn't want to demonstrate that there is there are no risk with cannabis but he wants to to demonstrate that it's very important to have a broader view of all the risks that exist with substances and that the fact that some substance, the decisions that government make to criminalize some substance and to give them illegal status doesn't mean that they are more dangerous compared to other and that's why that's not because alcohol is a load in a lot of countries that there are no risk with alcohol or with tobacco. And I think that it's important to have to have that in mind because for for example, we focused a lot on the cannabis because it's illegal in the majority of the majority of countries in Europe, but sometimes this focus on cannabis makes some governments totally forgot that there are also risks with alcohol and that's especially the case in France and due to economical arguments and that's why it's very important for me to say for cannabis and for alcohols that the public health needs to be always a priority and we need also to have a global perspective on prevention because the adolescents who smoke cannabis also drink alcohol and smoke tobacco and we need to have a broader perspective to address all the risks of these substances. Thanks Marie. Marika, do we have time for one more question? I just would like to, because there are many questions on the same topic that is synthetic cannabinoids, if you can say one word about it. Another question asks if you, when you analyze data for the demand on treatment, you also considered forced treatment, people that this sent to treatment. May be Jacob, would you like to say a word on synthetic cannabinoids in the context of our discussions? I think we've covered this maybe already, I'm not quite sure. So in the context of treatment, both we don't have the data for both synthetic cannabinoids and legal referrals or mandatory treatment. So right now, like I was trying to get the data for Germany, it's quite difficult. It's maybe possible, but it's just incredibly difficult. So and thinking about this on the European level would require initiatives like the EMCDDA to put this on their agenda. So this needs to be a priority for a political point of view, not really from the researcher point of view. Thanks, and I can also say as one of our mini guides there after the cannabis one, I think the number six or seven is going to be on responding to new psychoactive substances for those that are interested in reading more about the range of responses. That's also to Casano and synthetic opioids, but we will also be launching within the next two weeks, a publication on that slightly broader topic. And America, the last question was about considering in the demand for treatment people that is forced to treatment. And then this is really the last one because I think it's very important for us to hear from Alexis, his consideration on all this debate and we don't want to take too much of the time. So if you have a brief comment on this, I promise the people asking the questions that we will let them have to our speakers that you can answer through the email. Thanks. If I'm going to ask you any thoughts, is this something that Yes, I think that's the paradigm treatment instead of punishment so that people are put to treatment instead of prison. And as a therapist, it's not so easy if someone comes without any motivation for change, but that's, that's, that's the case very often so we apply motivational interviewing techniques and try to find something people like to change, particularly their cannabis use and associated problems, social problems, but in, there are European countries, for example, Poland with this shift and paradigm. This is a country where we trained a lot in the last 10 years. So they put a lot of money and effort to improve the treatment system and have very good health specialists, addictions specialist. And a big thank you for me really enjoyed this conversation and very much appreciate all the panelists input and for sharing their time and thoughts with us. Thank you for me back to America and Alexi. Thank you so while I share thank you to Alessandra the link to register for more news on our response guide I ask Alexis to intervene for his closing remark. Thank you very much, Marika and Jane and also I would like to seize the opportunity to congratulate and thank all the EMC DD staff that since last year, more than one year ago started engaging this new adventure of the EMC DD webinars. So you are all very committed and and we have fantastic experiences. And I think one of the key assets of the EMC DD webinars is that it's not EMC DD is speaking or not EMC DD is speaking alone but that we give the floor to the best possible experts to open and to the debate and not to bring a kind of a very unique or unique truth. So very difficult, certainly don't have the pretension to summarize everything that was said also it was so rich that I'm afraid I would have just to spend another half an hour to just highlight many of the things that have been said but my feeling during the webinar listening to to the presentations and the question and again Eva, Marie and Jakob, very really many thanks and I really look forward to meet you face to face in the real world, whether in Lisbon or Paris or Munich, wherever you are. So I think maybe we should speak about the cannabis paradox, because the more I listen to you the more I read on this the more I follow this issue. It's a real paradox we have a big stigma. Sometimes it looks like the same stigma as it applies for people who inject heroin or use other drugs that they have a much more damaging effect for their health. I don't mean that stigma justified of course in any case I think it's not justified at all. And clearly it's also from the perspective of the European Union strategy and action plan. There is a clear priority to fight against stigma. There is the issue of criminalization. And on the other side, it's not really considered as a priority for research. It's not really considered as a priority for innovative treatments. There is a kind of a social or political ignorance of the health consequences. And I was thinking that maybe one factor that can contribute to the fact that even in some hospitals, because it's not only about policymakers or politicians. I think ourselves 10, 15 years ago, I think the perception, even we as professionals we had of how dangerous was cannabis, certainly has changed over time together with knowledge but also among other things with the increase in the concentration in THC. Because if we compare the pot that was smoked in May 68 in the street of Paris, for instance, or in Berlin, and if we say today, we see today, there is such a difference in the content and the potential risk that means we don't talk about the same thing. I think one of the factors that are actually amplifying this or have contributed to amplify is the fact that we observe, I find more and more a kind of fragmentation of policies. We more and more deal only with little bits and pieces of a problem. I think it's partly due to the overall approach, including the last decades, there was an evolution in the concept of public management that was not always the best way to see public management, I think. And it's not only about drugs, even if certainly we can say, I think that there is a, from what we heard today, it just illustrates that there is a fragmentation of thinking drugs. And I would like to welcome a point that was made by each of you that I shared also myself at the Fédération Addiction Conference in MES online, in my case, 10 days ago. I think, yes, we need to start from the risks and not from the moral, it's not a question of moralistic approach. And I would say in French, we speak about Reduction des Risques, which is not exactly the same than talking about harm reduction. And I made the point that probably we need to reintegrate in the same concept the two elements, the risk and the harm, because for me, the risk behavior comes before the harm appears or not. So we need to avoid to fragment more. And I think when you say we need to move from treatment instead of punishment, I think it all illustrates the need overall to re-humanize. And when I say to re-humanize the policies, it's not just blah, blah, theory, philosophy. I think I give you a concrete example that I experienced in some of my field visits and in the context with some of the audience today and others. It's basically the solution for some of the problems we are talking about. It's not just the setting. It's not because you create a treatment center that you have solved the problem in the community and the debate on the DCRs in Paris or in Athens. I visited Okana with the President Sehocharis and he explained to me that the municipality was going to invest to provide some assistance to the people living in the neighborhood where they were going to open the new DCR. Because obviously, who would be crazy enough in places where there is a very huge social vulnerability if there was money spent for those people who are using drugs who are extremely socially deviant. And at the same time, there would be nothing done or offered to the citizens who live there longer time than the people who are using drugs and were facing a right range of problems. So these calls and actually it's not new. So to reach slowly but surely my conclusion for today. I think what we can share with you as CMCDDA is also the fact that we can and we have to learn from what we do for 30 years in Europe. Because yes, we have problems. Yes, we need more research. Yes, we need to be less dogmatic. I heard one day just when we launched the EMCDDA publication on the medical use of cannabinoids and we on purpose, we never speak about medical cannabis because there are so many components in cannabis plant that it makes no sense. We don't speak about therapeutic or medical Baobab, but in some cases we can speak about the use of morphine to treat cancer pain among children and there is a body of evidence that confirm that there is a possible use. But that person was interviewed on the national radio and she was saying that their association of pharmacies would oppose with all the energy, the development of any medicine that would contain TFC. And this is exactly the opposite of science. And if we were doing that, we would not allow ourselves to continue to use morphine, which is the best treatment for acute pain. There is nothing else that reached the same efficacy. And we see interesting developments that we should avoid to lose. Some initiatives about therapeutic use of LSD, the therapeutic use of MDMA for the treatment of post-traumatic disorders. In some cases recently the use of ketamine for treatment of certain forms of depression and I heard more recently even the use of GHB, if I'm not wrong, there are some clinical trials. So this calls for opening, having a more broader approach of the problem, but at the same time being more inclusive in terms of what is the information we, as the European Drugs Agency, we share with our customers, the EU and the nation and decision makers, but also in our support to the practitioners in demand and supply reduction, because I think we have a huge experience. Do you know, do you remember that 25, 30 years ago in Spain, the National Action Plan on Drugs was organized encouraging not only the autonomous communities, but the cities to have a member of the council in charge of drug. They even organized training for them to have more comprehensive policies. So we have a body of experience we should be more aware of, but we cannot already use. And certainly to finish, I would say I would thank again the participants, the audience, all three guests, and I would make a plea together with you, not for us, not for our budget, but, but for the fact that for many of those topics you have mentioned today, like for others, we are covering with the work of the MCDD, we need more and better research. And when I say more and better research, I don't think only about quantitative research, but also qualitative and certainly the evaluation of services is a key element today and even more in the future. But I really believe it cannot be addressed only with statistics and quantitative research. We need also, there is good and as a qualitative research is as scientific as quantity quantitative, it's just different. And the use of the results is different, but we need both. Thank you very much. Thank you very much Alexis. Rehumanizing will become one of the next keyword for many of us. We recognize we didn't answer all the questions, we will facilitate communication among the speakers and the audience that has still question. I thank you, Jane for her chairing this very, very interesting and also complex discussion. I will launch a poll for our public just to make sure we know what is their opinion, but you can leave if you have other other issues to handle. I will remain a few minutes to give people time to answer our poll. Register to the newsletter for the response guide and be with us for the next webinar will be in the legal status and the debate around European countries and then as Jen said, more on cannabis. Thank you very much everybody.