Driving and Marijuana

With the legalization of marijuana fast approaching (The Government of Canada is now saying “sometime this summer”), it was only a matter of time until one of my patients asked this question:

“Dr. Beck, how much marijuana will I be able to use and still drive?”

“I didn’t think you were driving yet.”

“I’m not driving officially, but I’m going to get my G1.”

“So, you don’t even have a G1 and you’ll be too young to buy marijuana legally, but you want to know how much you can use and still be able to drive. Is that what you’re asking me?”

“Well, when you say it that way, it makes it sound like I shouldn’t consider this at all, but I’d like to know.”

In fairness to this young person, I should say that both youth and parents are asking me similar questions, so I decided to see what I could learn about driving under the influence of cannabis. For the purposes of preparing this short review, I used three main references. One reference is a comprehensive report entitled Developing Science-Based Per-Se Limits for Driving under the Influence of Cannabis: Findings and Recommendations of an Expert Panel. The report was written in 2005 and includes a thorough summary of the Empirical Research on cannabis and driving. I checked with the Medical Librarian at my hospital to see whether they could find a more recent and as comprehensive report. Since they could not, I highly recommend this excellent, comprehensive reference.

I also reviewed the research of the American Automobile Association and the Canadian Automobile Association which, while not as comprehensive, is much more understandable for most readers. I will use these a references for most people who ask me for information.

Finally, I regularly review the Government of Canada and the Government of Ontario websites for updates on the legalization of cannabis. The Government of Ontario has determined that the Ontario Provincial Police will use Oral Fluid Screening Devices for roadside testing of cannabis. There are some concerns regarding the reliability of the devices and, since the Expert Panel Report recommended blood levels only as a means of measuring cannabis levels, it seems that cannabis will be introduced without clear guidelines regarding impairment comparable to Blood Alcohol Levels.

When discussing driving safety while using any substances with parents and youth, I always stress that a person should never drive if they feel at all affected by what they have ingested. As most people know, the extent to which a person can feel affected by a substance they ingest can vary widely from person to person, but, if an individual is being honest with themselves, this can be a very reasonable guideline.

For those wanting something more precise related to cannabis use, I did determine a straightforward guideline from the information in the Expert Panel Report. The report reviewed the results of all the epidemiological studies related to driving and cannabis use and performed a meta-analysis of the experimental studies.

In reviewing all the studies, the panel reminded the reader that there are 3 phases of impairment due to cannabis use. There is an acute phase, during the first 60 minutes following smoking cannabis. Then there is a post-acute phase that presents 60-150 minutes after use. There is, finally, a residual phase, occurring 150 minutes after ingestion. The panel members concluded that most studies showed that the impact on driving skills is minimal during the residual phase. This means that, depending on the amount of cannabis smoked, most people will no longer be affected 3-4 hours after smoking 20 mg of cannabis. This is the basis of the guideline I am providing: Don’t drive for 3-4 hours after smoking cannabis, depending on the dose. (Note: The studies also showed that there are differences in the timing of impairment after smoking cannabis, as compared with oral ingestion. Impairment relation to oral ingestion of cannabis peaks 2-3 hours after consumption, while impairment after smoking cannabis peaks at one hour.)

I like this guideline because it is clear and straightforward, although I am also reminding the young adults in my practice that most of them would never go out for an evening during which they might drink at all without a designated driver. My own practice suggests that, as far as alcohol is concerned, most youth I know would never drink and drive. Why not also have the same “designated driver” system when using cannabis?

As I review these studies and reports in conjunction with the information being provided by the federal government, I continue to be concerned about the lack of foresight in legalizing cannabis in Canada. It seems to me that the amount of time needed to ensure the safe legalization of cannabis might have been more accurately predicted. If the timing was not well-managed, can we really be sure that other aspects of legalization will be handled safely?

(photo credit)

Not Just Any Village

In recent months, I have come to learn more and more about the difficulties indigenous youth have in obtaining mental health services. In part, this is because local, provincial and federal news reports are calling attention to these difficulties but I am also very much aware of the needs of these young people in my own community and practice.

It is especially distressing that, despite the goodwill of governments and their financial investment, all the measures that have been taken seem to have no impact. How can this be?

I have come to understand this only in the context of being a mother myself and it is only using this reference point that I can make sense of why our efforts have been so ineffective. Let me see if this helps you to understand what is missing.

Imagine that your child has serious mental health problems. She is twelve years old and started using substances like cannabis, or alcohol, or solvents. (I have seen indigenous youth who started using substances, especially solvents, as young as seven years old.) School is a struggle and because of this, the child feels hopeless about the future. Perhaps as a parent, you can understand this because you were in the same situation at her age. You are desperate for your child to get help and so you agree that she should travel hundreds of miles away from home to get that help. You agree to this even though you will miss her desperately, and worry about her all day, every day. You know she is anxious and will cry because she misses you and her family, but you know that you cannot travel with her because there are other children to care for, or your job, or even because you yourself do not have the emotional strength to support her. Who cannot relate to the desperation of this situation? Of this parent? Of this child?

The research evidence is overwhelming that children’s health depends on family support. It takes the first year of our life to be able to walk. It takes us until we are two to utter a few words. We begin to have the skills to read, and write, and do math around age five. The evidence says that our enormous brains can take until age 25 to fully develop. We clearly need personal support to grow and develop and every culture relies on families to provide that support. When we are unwell, we need that support even more.

How do we expect these children to heal when we send them away from their families? If we must do this, could we not at least set up those sophisticated telehealth networks and facetime for parents and children and grandparents and brothers and sisters to stay in touch? “It takes a village to raise a child” is an African proverb that recognizes the universal truth that we need our families and kin – our village.

When I am having a hard day, I will often count my blessings and the blessings I remember first are the people of my personal village: my children and husband and family and friends.

Do we really believe that indigenous youth (or any youth) will become stronger mentally away from their families? Have we really learned nothing from the experience of those sent away to residential schools? Are we really not listening?

If those African philosophers will permit, I do have one slight modification to their proverb. I agree that it takes a village to raise a child, but not just any village will do. Each child deserves the support of their own village: their own family, their own friends, their own people.

(Photo credit: Family Ties sculpture by Kevin Barrett)

Ministers

I am getting pretty fed up with Health Ministers. Ontario’s Minister of Health and Long Term Care, Eric Hoskins, dumped a “deal” on the table for Ontario doctors at 8 a.m. last Wednesday morning. He was in a press conference by 9 a.m. letting the public know that he had offered Ontario doctors more money than he had in August 2016. Not mentioning that the doctors had rejected that August deal, the Minister also neglected to say that he had decided to pit groups of doctors against each other with his most recent offer. His latest “deal” seems to give family physicians an increase at the same time as it cuts the highest paid specialists.

The “increase” to family physicians is very questionable since the terms and conditions to which extra funding is tied are so stringent that doctors would take a loss in order to meet the Minister’s demands. The timing of the offer is also suspect. It follows hard upon the passage of Bill 41, the so-called Patients First Act, which seeks to address problems in Ontario’s health care system with additional bureaucracy and a Command-and-Control approach that is totally unnecessary given the work ethic and devotion of most doctors. The Board of the Ontario Medical Association unanimously condemned the actions of the Government of Ontario and the Minister of Health and Long Term Care.

Hard upon this, now consider the federal government’s “Take it or leave it” offer to the provinces of an “increase” of $11.5 billion for home care and mental health. That’s meant to be an investment over the next TEN YEARS, for all Canadians. That’s an investment of about $300 for every Canadian. This is not more than a week’s worth of home care or 2 sessions with a clinical psychologist. Dr. Granger Avery, the President of the Canadian Medical Association, said, “The Groundhog Day-type discussions where political leaders bat around percentages and figures at meetings in hotels have to stop.”

Really, Ministers, doctors would like to be able to have a real discussion about a health care proposal that you introduce that does not require the use of quotation marks to alert the public to the fact that health ministers and doctors speak a different language, especially where money and patient needs are concerned.

As a physician, I would like to think that there is an opportunity to discuss why these proposals will not meet the needs of my practice. As a patient, I want analysis that demonstrates to me that the investment of my money has been careful and methodical and that investments are linked to outcomes that both my doctors and the government agree on. As a citizen, it is distressing to be a bystander to this grandstanding by legislators. This is people’s healthcare. You are governing. Please consider your proposals with the seriousness they deserve. Please talk with me, not at me.