Regulatory Policies for Alcohol, other Psychoactive Substances and Addictive Behaviours: The Role of Level of Use and Potency. A Systematic Review
2. Material and Methods
3.2. Other Substances and Gambling
Conflicts of Interest
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|Unit measured to define “heavy use over time” in epidemiology||gram ethanol ( = pure alcohol)/day||cigarettes/day (as rough indicator of level of nicotine intake)||frequency of use||joints per day/week||average money spent per day |
|Measure of potency of psychoactive “ingredient”||ethanol concentration||nicotine concentration; other addictive additives||opioid concentration (i.e., morphine equivalents )||THC concentration||potential for average losses per minute |
|Other impacts on the potency (psychoactive ingredient)||Speed of delivery [18,91], food (absorption ; elimination ); tolerance; other individual factors (sex, age, body, weight )||Diverse factors according to delivery mode (e.g., holes for air to enter); speed of delivery ; individual factors||Speed of delivery, which can be manipulated by mode of administration, and which impacts on bioavailability and on onset of action ; tolerance ; other individual factors||Diverse factors, depending in part on mode of delivery; level of other cannabinoids  tolerance; other individual factors.||Reward parameters (e.g., jackpot size), timing parameters (e.g., speed of play, event frequency) [89,98]|
|Is the level of the psychoactive ingredient a guiding principle for regulation||In most jurisdictions, yes: taxation and drink-driving policies based on grams of ethanol [30,31] and blood alcohol content , respectively||Not yet in most countries, as light products are usually not differently taxed or treated by law. However, there are efforts to limit potency by law (e.g., for the US: [99,100]).||Only in part relevant for illegal opioids. Some jurisdictions have been banning (or refusing to allow) prescription opioids deemed to be high-risk due to potency but also formulation (e.g., short-acting, crushable, or otherwise easily manipulated). E.g., in 2016, Ontario de-listed several higher-strength opioids from the Ontario Drug Benefit formulary . On the other hand, low potency products (e.g., codeine) are sometimes exempt from prescriptions.||Not relevant for illegal cannabis. In Canada, legal cannabis products were initially taxed per gram (i.e., no potency considerations). Dried cannabis and seeds are still taxed this way but oils are now taxed by THC content. The classes or products being permitted in 2019 (edibles, extracts and topicals) will also be taxed by quantity of THC .||There are regulations on|
1) maximum spend per hour, day (e.g.,  for the Netherlands), with sometimes distinctions on where the gambling takes place; or on the 2) maximum that can be spent by bet (e.g., the UK implemented, as of April 2019, £2 bet limits on certain EGMs (more or less equivalent to slot machines )).
In additions, restrictions based on location are possible based on potency (e.g., high potency for casinos only ).
|Can direct short-term effects be lethal?||Yes, in some jurisdiction alcohol poisoning is a major cause of death (e.g., Russia ).||Yes, but such cases are rare .||Yes, in some jurisdictions opioid overdose is a major cause of death (USA ; Canada ).||No, not with plant-based cannabis. However, synthetic cannabinoids can be lethal .||No|
|Are there different subcategories of psychoactive substances/devices?||Yes: beer, cider, mixed drinks, wine, fortified wine, spirits (e.g., for a distribution of main beverage types by country, region, and globally ).||Yes: the Tobacco Framework Convention defines tobacco products as “products entirely or partly made of the leaf tobacco as raw material which are manufactured to be used for smoking, sucking, chewing or snuffing” ; new products considered are “Heated tobacco products” or “electronic nicotine delivery systems”, the latter not a tobacco product .||Yes: based on two dimensions. First, there are illegal and medicinal products. Second, there are different categories of opioids such as codeine, fentanyl, heroin, morphine.||Yes: based on two dimensions. First, there are illegal and medicinal products; and in select jurisdictions legal recreational products. Second, there are different categories of cannabis such as smokable or edible products||Yes: e.g., casino gambling without electronic gambling machines (EGMs); EGMs; lotteries; Internet gambling; horse racing and other betting on animal contests . Regulation is mainly concerned with commercial gambling.|
|Do subcategories differ in potency?||Yes||Not necessarily; some of the electronic nicotine delivery systems have higher potency .||Different opioids (e.g., fentanyl, heroin, codeine) differ in potency; however, the distinction between illegal and medicinal products is not relevant, as both subcategories can have different potencies.||Both illegal and medicinal products can have different potencies, so this distinction is not relevant for potency; however, different plants and types of cannabis differ in potency. In addition, synthetic cannabinoids can have higher potency .||Yes|
|Evidence for justifying different regulations for different subcategories based on addictive potential||For causing alcohol use disorders: weak evidence for differentiating subcategories .||All product classes may lead to tobacco use disorders based on nicotine concentration and the device used.||All categories of opioids may lead to opioid use disorders, depending on different factors including potency [114,115,116].||Both illegal and medicinal cannabis may lead to cannabis use disorders, depending on different factors including potency [117,118].||Yes, electronic gambling machines were associated with higher risk of gambling addiction as defined by ICD ([89,119] but )|
|Evidence for justifying different regulations for different subcategories based on overall harm||More potent forms of alcohol such as spirits were associated with more unintentional and intentional injury [63,71,72]. While in the underlying epidemiological research, patterns of drinking often were not controlled for, experimental research also showed that spirits led to higher blood ethanol concentration and psychomotor impairment, even if the overall ethanol intake was the same [63,71].||There are differences in overall harm of different tobacco products and of electronic nicotine delivery systems [121,122]. The reason for these differences can be explained by the fact that many other ingredients of cigarettes and other tobacco products over and above nicotine impact on morbidity and mortality . In other words, while nicotine has been linked to morbidity and mortality [123,124,125,126], even cigarettes without nicotine would have markedly detrimental health effects.||Health harm, especially overdoses, seems to be mainly based on dose, which is linked to potency (, but see ), not on the distinction between medicinal and other products. The recent fentanyl crisis in North America certainly has been linked to high potency of this opioid, its synthetic analogues and other synthetic opioids [128,129]. Obviously, legal problems as a form of harm by definition only apply to illegal products.||No indication that medicinal products have less health harm; obviously, legal problems as a form of harm are only relevant for illegal products. Synthetic cannabinoids may cause higher harm . Overall, while cannabis use can cause health harm , the level of this burden is much lower than for other substances [3,130]), even when considering prevalence of use .||Certain structural characteristics of EGMs have been identified as strongly associated with harm, including high speed of play, losses disguised as wins, near misses, and features that give the user the illusion of control .|
|Evidence on harm to others (see also  as overview of harm to others from substance use)||Considerable harm to others (highest of all substances in the comparative study of ), in part linked to patterns of drinking (traffic injury, FASD; ) and maybe to potency (violence and other injury [63,71]).||Considerable health harm to others, mainly known for cigarette smoking .||Considerable harm to others via needle sharing (infectious disease;  and traffic injury ).||Harm to others via traffic injury .||Yes, but lesser degree than substance use, mainly to families and immediate environment, and no fatal outcomes |
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Rehm, J.; Crépault, J.-F.; Hasan, O.S.M.; Lachenmeier, D.W.; Room, R.; Sornpaisarn, B. Regulatory Policies for Alcohol, other Psychoactive Substances and Addictive Behaviours: The Role of Level of Use and Potency. A Systematic Review. Int. J. Environ. Res. Public Health 2019, 16, 3749. https://doi.org/10.3390/ijerph16193749
Rehm J, Crépault J-F, Hasan OSM, Lachenmeier DW, Room R, Sornpaisarn B. Regulatory Policies for Alcohol, other Psychoactive Substances and Addictive Behaviours: The Role of Level of Use and Potency. A Systematic Review. International Journal of Environmental Research and Public Health. 2019; 16(19):3749. https://doi.org/10.3390/ijerph16193749Chicago/Turabian Style
Rehm, Jürgen, Jean-François Crépault, Omer S.M. Hasan, Dirk W. Lachenmeier, Robin Room, and Bundit Sornpaisarn. 2019. "Regulatory Policies for Alcohol, other Psychoactive Substances and Addictive Behaviours: The Role of Level of Use and Potency. A Systematic Review" International Journal of Environmental Research and Public Health 16, no. 19: 3749. https://doi.org/10.3390/ijerph16193749