In September 2018, South Africa saw the constitutional court deliver a ruling on the private cultivation, possession and consumption of cannabis – in what some saw as a landmark judgement (Allers et al., 2019; Kriegler, 2018). On the other hand, concern and confusion raised by the ruling, should hopefully be settled by September 2020 – when detailed rulings on the matter are released (Kriegler, 2018). This post aims to unpack some of the implications involved in the ruling of cannabis use within a South African context, taking various factors into consideration. Factors include: the country’s already existing substance abuse problem; the legacy of Apartheid; limited and conflicting available research on cannabis use, the many definitional frameworks which exist in understanding addiction; and available treatments. These factors are considered in the proposal of an intervention strategy for the management of cannabis use disorder in a vulnerable South African population.

Clinical Characteristics and Risk Factors Associated with cannabis Use Disorder

Many definitional frameworks exist in the understanding of addiction and what constitutes use, abuse and dependence, (Maddux & Winstead, 2015). The Biopsychosocial perspective sees symptoms of addiction as manifestation of a disease (Maddux & Winstead, 2015). The Behavioural approach, on the other hand, looks into the complex interaction of ‘nature and nurture’ in producing and maintaining addictive behaviour- taking societal norms into consideration (Maddux & Winstead, 2015). Finally, The Disease-Moral Model of Addictive Behaviour focuses on addiction from a social policy perspective. This method holds the contradictory tendency to view addiction as either an “illness” to be treated in addiction therapy groups, or a crime to be punished via incarceration (Maddux & Winstead, 2015).

Ultimately, cannabis use disorder (as with any addiction) comes down to ‘a behavioural pattern which can be characterised by an overwhelming pathological involvement in or attachment to the substance use, and an inability to exert control over it – despite any negative impact on physical, psychological and social functioning’ (Maddux & Winstead, 2015). A person’s vulnerability for substance related disorders might originate from a combination of factors including biology, genetics, environment, socio-cultural, and biochemical processes (Maddux & Winstead, 2015; Muchiri & Dos Santos, 2018; Palmer et al., 2015). Overall, these factors make the person value drug use highly, even if it might be against their long-term interest (Heshmat, 2017)

Not only is cannabis a misunderstood substance (Kosty et al., 2017).- with unclear and heterogeneous risk factors, trajectory patterns, aetiology, course and outcomes – but there are limited data available on the prevalence and patterns of its use – globally, as well as within a South African context (Maddux & Winstead, 2015; Peltzer et al., 2010). Recent initiatives to provide more valid and reliable information about illicit drug use in South Africa provide valuable information on profile and drug use – but important gaps remain to be addressed (Peltzer et al., 2010). Though cannabis use is popular among all ethnic groups, both in low and higher income groups, it is most prevalent in African households (Peltzer et al., 2010) – especially female-headed households who have the lowest average income in South Africa (Dunga, 2017). Risk factors tend to include adolescence or young adulthood age group, male gender, low education performance, African or coloured ethnicity, who come from divorced parents, and/ single-headed female households (Muchiri & Dos Santos, 2018; Peltzer et al., 2010)

Evaluation and Discussion of the South African Context

The misuse of cannabis cannot be viewed in a vacuum, especially in a country like South Africa, which has been undergoing major transition. It has been argued that changes in the political, economic, and social structures within the country, both before and after Apartheid made it more vulnerable to drug use (Peltzer et al., 2010). The issue of substance abuse and structural problems in South Africa is cyclical; whereby one exacerbates, and is exacerbated by, the other. Furthermore, the Apartheid legacy not only left people susceptible to substance use and abuse, but made it difficult to treat the problem.

Those who may be more susceptible to substance abuse and come from unfortunate communities have very few systems in place to protect and rehabilitate them. Inadequate governmental services include law enforcement, health care facilities, alcohol/drug user treatment programs, schools, and research funds and facilities (Peltzer et al., 2010). Uneven public education in these communities has made it difficult to control or monitor the youth (Peltzer et al., 2010); leaving them susceptible to substance use and abuse.

Structural problems in South Africa, such as rapid modernisation and slow redistribution of economic power, difficult social transformation, decline in traditional social relationships and family structures, high unemployment rates, and uneven public education create conditions which foster drug use (Peltzer et al., 2010). Additionally, as way of dealing with the issue of unemployment and poverty, people in informal settlements and townships often rely upon the sales of illegal drugs (Peltzer et al., 2010). Lack of resources to deal with crime also contributed to an increase in accessibility and availability of illicit drugs in the country (Peltzer et al., 2010).

The fact that substance abuse correlates with experiences of violence and trauma (Maddux & Winstead, 2015) highlight the danger of South Africans turning to substances to help with the overwhelming issues which exist in a country rife with trauma and violence. Kosty et al., (2016) shows us that there is an increase in illicit substance use during adolescence. Stressful life events (such as parental divorce, childhood trauma/ maltreatments, growing up in a single parent household) can serve as risk factors for substance use in adolescents. Some core reasons driving the more risky subpopulations in South Africa to use and abuse substances are mood-change and coping with hardships (Peltzer et al., 2010). People who use substances do so as a form of release or escape from conditions of social and/or personal misery; (Peltzer et al., 2010).

Potential Implications of Legalizing cannabis in South Africa

Even before the ruling, when cannabis was illegal on all grounds, the drug was still easily available and commonly used throughout the country (Maddux & Winstead, 2015 ;Peltzer et al., 2010), particularly among the youth (Lubman et al., 2015). South African drug user treatment centres were experiencing a rise in substance user treatment admissions (Dada et al., 2016; Peltzer et al., 2010) and an estimate of results showed that cannabis use came second to alcohol abuse (Maddux & Winstead, 2015). Therefore, despite whether the ruling aggravates the problem or not, substance abuse is already a prevalent issue in the country (Dada et al., 2016; Maddux & Winstead, 2015; Peltzer et al., 2010); cannabis was already widely used and in the hands of the youth of South Africa.

As the ruling currently stands, cannabis is not entirely legal, nor has it been regulated or taxed by the state. Without a set of standards for quality and safety control, responsibility lies within the hands of the adults who cultivate, possess and use it. Hopefully the defined laws on legislation, September 2020, will create a set of standards for quality and safety control. This seems to have worked in the alcohol and tobacco industries, and should transfer into the cannabis industry (Herrmann et al., 2018). Improved quality and safety control should put less weight on the medical system – which is already overburdened in the country (Burns, 2014; Lund et al., 2010).

There are risks involved with cannabis use for vulnerable populations. Biopsychosocial models claim that cannabis use involves tolerance and withdrawal, much like any addiction (Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 2013). Even though majority of cannabis smokers do not develop an addiction, a small group of vulnerable users do develop all the symptoms of an actual addiction after chronic cannabis use (Kosty et al., 2017; Palmer et al., 2015; Patel & Marwaha, 2019). Despite difficult in truly ascertaining the addictive quality of cannabis, we do know that addiction leads to significant problems across multiple domains of functioning (Maddux & Winstead, 2015) and that – like alcohol – cannabis alters perception, which can be dangerous if not used responsibly (Freeman et al., 2018).

In addition to its perception-altering and possibly addictive properties, cannabis has long been considered a gateway drug – meaning that using it might lead to more serious illegal substances (Hal & Lilienfeld, 2012). If cannabis legislation results in an increased number of individuals trying cannabis and eventually moving onto harder drugs (Hal & Lilienfeld, 2012), this could put more financial pressure on the country’s already-fragile systems (Maddux & Winstead, 2015) to provide treatment for these individuals.

Another daunting factor of concern is the correlation between cannabis and mental health. Substantial evidence suggests an association between early and frequent cannabis exposure in adolescence and psychotic experiences – as well as negative psycho-social effects (Kosty et al., 2017; Lubman et al., 2015; Paruk & Burns, 2016; Sami, 2018;). Matters of concern include restricted blood flow to the brain, memory loss, and increased likelihood of schizophrenia and depression (Mokoboto-Zwane, 2018; Muchiri & Dos Santos, 2018). Researchers do not know if the drug itself triggers schizophrenia and depression or if cannabis users use the drug to alleviate and deal with the symptoms of pre-existing mental health conditions (Kosty et al., 2016; Sami, 2018). Science is still not completely certain about these negative assertions; “it remains contested whether a cause-and-effect relationship between smoking cannabis and schizophrenia truly exists.” (Sami, 2018).

Intervention Strategies in Place for Managing cannabis Use Disorder

Neither one of the multiple frameworks which underlie available intervention (in understanding the problem of addiction) stand perfect in isolation. The Biopsychosocial perspective does not account for other factors underpinning addiction, other than labelling a behaviour as a disease. This view may hold consequences for people suffering from addiction and risks not being cross-culturally applicable to assessment, diagnosis and treatment of people within multiple contexts. The Sociocultural view focuses only on societal and cultural norms that show the socially accepted standards for use of a substance. Finally, the Disease-Moral Model of Addictive Behaviour holds divergent and contradictory views about aetiology and maintenance of addictive behaviour. This confused approach unfortunately, tends to drive policy (Maddux & Winstead, 2015). The circumstances of this are that drug users have been treated as either criminals or sinners (Maddux & Winstead, 2015).

In approaches which support the Disease-Moral Model of Addictive Behaviour, the vulnerable groups who fall victim to addiction need care and attention – not to be punished, but treated. Ultimately a diagnosis should reflect on a person’s need for additional care and attention; that there is reason to be concerned for their safety. Labelling people as criminals and ostracising them is not helpful in treating the problem. The vulnerable groups who fall victim to addiction need care and attention. Instead of being punished these patients should be treated.

Group therapy or some form of Psycho-Socio therapy – similar to Alcoholics Anonymous (AA) or other Twelve Step Facilitation (TSF) programs – are the most popular self-help groups for treating addiction. Important elements that arise from these programs are a sense of community, acceptance, belonging, encouragement and connection to a spiritual underpinning (Maddux & Winstead, 2015). Treatments which have shown promise, according to Winstead and Maddux (2015) are Cognitive-BehTheavioural Therapy (CBT) and Motivational Enhancement Therapy (MET). In cooperation with these treatment methods, a spiritual belief practice such as mindfulness meditation can be highly beneficial. MET focuses on a person’s motivation to change in a directive, client-centred manner. It is designed to assist clients with exploring and resolving ambivalence (Winstead and Maddux, 2015). CBT’s focus is on teaching coping skills, and has proven to be most popular (Winstead and Maddux, 2015).

Etiology, course and treatment are controversial and complex (Maddux & Winstead, 2015). Thus, even though multiple theoretical conceptualisations exist in defining the problem of addiction, there is fundamental disagreement about whether to view addiction as a disease in need of medical treatment, a sin in need of punishment, or learned behaviour that can be changed (Maddux & Winstead, 2015). The goal of treatment has been to reduce the severity of symptoms, consolidate treatment gains, and finally to prevent relapse and improve overall functioning (Maddux & Winstead, 2015). However improving relapse and overall functioning of an individual involves much broader structural issues in a country or society.

It is evident that a broad variety of treatment options already exist. However, they may have remained outdated in their understanding and method of the problem, or only looked at it from mainly a singular perspective. Given the complexity of addictive behaviour, a binary view is far too simplistic to address the issue. This paper proposes a multiple-intervention program which addresses denial and stigma, is easily accessible and cost effective (ideally government funded), provides services which make it more inclusive; and meets the needs of the vulnerable subpopulations in South Africa. A multidimensional, multidisciplinary effort is needed to match the complex process of addiction. In order to address the complexities, we must rise to the level of the problem and meet it at as many angels as possible.

More training of multi-disciplinary teams who are able to employ psychosocial interventions would aid to assist the addiction problem in South Africa. Prevention and intervention policies need to be designed in a more holistic and inclusive manner in order to reduce high drug abuse admission levels and target the more risky subpopulations (Peltzer et al., 2010). It is crucial to bear in mind that, any positive effects in treatment may be lost to the vast structural issues faced by South African citizens – particularly the impoverished youth. Vulnerable groups face the unfortunate problem of having to go back to the community which got them into substance abuse to begin with. Due to the particularly high use among the youth, it is important that intervention places emphasis on discouraging cannabis consumption among or near children.

It is important that frameworks exist which serve to protect these substances from being exploited by children, and that education is available on the substance – supplied by addiction centres and offered in subjects like Life Orientation at school so that the youth are informed about the possible affects the substance could have on their developing brain.

If it turns out that cannabis is fully legalised, it should be accepted and governed by social custom that allows people the opportunity to learn constructive norms for use and makes it more difficult for the youth to obtain. Furthermore, as a society we need to create a sense of disapproval of misuse and misbehaviour under the influence (Maddux & Winstead, 2015). A positive outcome would rest on informed, strict rules and values that govern the circumstances of cannabis use. We cannot simply rest our trust that mature, informed adults would be responsible users who would go to great lengths to protect the youth. Some adults themselves are vulnerable too.

Despite the uncertainty of where legislation will take the country, interventions need to be in place and improved in dealing with addiction in general. This is a compounded problem, which would be unrealistic to expect to change overnight. Research, treatment and social policy should, as much as possible, account for all angels of the problem until science is better able to provide more conclusive answers, and should strive to continuously evolve as the answers unravel.

Conclusion

South Africa’s constitutional court ruling on the private cultivation, possession and consumption of cannabis may or may not increase the addiction rates in the country. Regardless of implications, the risk of addiction needs to be dealt with and facilities need to be prepared, as this is already a major problem in the country.

It is complicated to isolate the problem of cannabis use disorder. Society’s understanding of addiction is incomplete. In addition, the extent to which risk factors, aetiology, course and outcomes distinctly associated with cannabis use trajectory patterns are unclear. Individuals who use cannabis cannot be regarded as a single homogenous group, yet we do know that some people face more susceptibility in becoming addicted to the substance than others. Susceptibility of substance abuse in South Africa is compounded by a harsh landscape- still affected by its difficult history. The subpopulations which should be of particular focus are the lower income and youth groups.

Much more research is needed to fully understand the effects of cannabis – especially within a South African context. The history of Apartheid left the country with very limited resources to combat the issue of addiction. Thus, government needs to address the enormous inequalities which remain. Interventions should aim to draw from as many resources as possible, and evolve with the research, while placing a particularly strong focus on the vulnerable groups. Implementing frameworks which serve to protect substances from being exploited by minors is one method.

South Africa as a whole needs to shift its perspective to one of additional care, concern and attention to the individuals who find themselves susceptible to substance abuse. Labelling people as criminals and ostracising them is not helpful in treating the problem. The vulnerable groups who fall victim to addiction are symptoms of much larger structural and societal problems, and are in need of additional care and attention – not punishment or judgement. Addiction is a compounded problem, and it would be unrealistic to expect change overnight. However, one thing that needs to change is the unidimensional perception of the problem as it is far too simplistic to address the problem. It is short sighted to assume that any one of approach on its own would be enough to tackle cannabis abuse disorder, among addictive behaviours in general. This paper proposes a multi-dimensional intervention method to help bear the multiple complexities involved in cannabis Use Disorder within the South African context.

References

Allers, E., Domingo, A. K., & Nowbath, H. (2019). The new cannabis law in South Africa. Mental Health Matters, 6(1), 1–2.

Burns, J. (2014). Social and ethical implications of psychiatric classification for low- and middle-income countries. South African Journal of Psychiatry, 20, 66. https://doi.org/10.7196/sajp.589

Dada, S., Burnhams, B. H., Erasmus, J., Parry, C., Bhana, A., Timol, F., Nel, E., Kitshoff, D., Weimann, R., & Fourie, D. (2016). South African Community Epidemiology Network on Drug Use (SACENDU): Monitoring alcohol, tobacco and other drug abuse treatment admissions in South Africa, September 2016 (Phase 39).

Diagnostic and Statistical Manual of Mental Disorders (DSM-5). (2013). American Psychiatric Association.

Dunga, S. (2017). A Gender and Marital Status Analysis of Household Income in a Low-Income Township. Studia Universitatis Babes-Bolyai Oeconomica, 62. https://doi.org/10.1515/subboec-2017-0002

Freeman, T. P., Wilson, J., & Mackie, C. (2018). Commentary on Salloum et al. (2018): Rethinking adolescent cannabis use and risk perception. Addiction (Abingdon, England), 113(6), 1086–1087. https://doi.org/10.1111/add.14212

Hal, A., & Lilienfeld, S. O. (2012). Experts Tell the Truth about Pot. Scientific American. https://www.scientificamerican.com/article/the-truth-about-pot/

Herrmann, E. S., Jarvis, B. P., Sparks, A. C., Cohn, A. M., Koszowski, B., Rosenberry, Z. R., Coleman-Cowger, V. H., Pickworth, W. B., & Peters, E. N. (2018). Sweet flowers are slow, and weeds make haste: leveraging methodology from research on tobacco, alcohol, and opioid analgesics to make rapid and policy-relevant advances in cannabis science. International Review of Psychiatry (Abingdon, England), 30(3), 238–250. https://doi.org/10.1080/09540261.2018.1465400

Heshmat, S. (2017). 7 Common Reasons Why People Use Drugs. Accessed 4 April, 2020, on: https://www.psychologytoday.com/sg/blog/science-choice/201711/7-common-reasons-why-people-use-drugs

Kosty, D. B., Seeley, J. R., Farmer, R. F., Stevens, J. J., & Lewinsohn, P. M. (2017). Trajectories of cannabis use disorder: risk factors, clinical characteristics and outcomes. Addiction (Abingdon, England), 112(2), 279–287. https://doi.org/10.1111/add.13557

Kriegler, A. (2018). Marijuana use in South Africa: what next after landmark court ruling? The Conversation. http://theconversation.com/marijuana-use-in-south-africa-what-next-after-landmark-court-ruling-103607

Lubman, D. I., Cheetham, A., & Yucel, M. (2015). cannabis and adolescent brain development. Pharmacology & Therapeutics, 148, 1–16. https://doi.org/10.1016/j.pharmthera.2014.11.009

Lund, C., Oosthuizen, P., Flisher, A. J., Emsley, R., Stein, D. J., Botha, U., Koen, L., & Joska, J. (2010). Pathways to inpatient mental health care among people with schizophrenia spectrum disorders in South Africa. Psychiatric Services (Washington, D.C.), 61(3), 235–240. https://doi.org/10.1176/ps.2010.61.3.235

Maddux, J. E., & Winstead, B. A. (2015). Psychopathology: Foundations for a contemporary understanding. Routledge.

Mokoboto-Zwane, S. (2018). Comorbid Schizophrenia And cannabis Use Disorder In South Africa: Perspectives Of The Mental Health Care Users (MHCU’s) On Relapses. Journal of Practical & Professional Nursing.

Muchiri, B. W., & Dos Santos, M. M. L. (2018). Family management risk and protective factors for adolescent substance use in South Africa. Substance Abuse Treatment, Prevention, and Policy, 13(1), 24. https://doi.org/10.1186/s13011-018-0163-4

Palmer, R. H. C., Brick, L., Nugent, N. R., Bidwell, L. C., McGeary, J. E., Knopik, V. S., & Keller, M. C. (2015). Examining the role of common genetic variants on alcohol, tobacco, cannabis and illicit drug dependence: genetics of vulnerability to drug dependence. Addiction (Abingdon, England), 110(3), 530–537. https://doi.org/10.1111/add.12815

Paruk, S., & Burns, J. K. (2016). cannabis and mental illness in adolescents: a review. South African Family Practice, 58(sup1), S18–S21. https://doi.org/10.1080/20786190.2014.978106

Patel, J., & Marwaha, R. (2019). cannabis use disorder. StatPearls Publishing.

Peltzer, K., Ramlagan, S., Johnson, B. D., & Phaswana-Mafuya, N. (2010). Illicit drug use and treatment in South Africa: a review. Substance Use & Misuse, 45(13), 2221–2243. https://doi.org/10.3109/10826084.2010.481594

Sami, M. (2018). Rise in cannabis Strength May Not Affect Rates of Schizophrenia, New Study Suggests. Independent. https://www.independent.co.uk/life-style/health-and-families/cannabis-use-schizophrenia-no-evidence-weed-marijuana-smoking-study-psychotic-problems-a8273956.html