The health, economic, and social effects of cannabis use in Thailand

Study design

This was a prospective cohort study design. Kalasin province in the northeast of Thailand was selected as the study site because it is a major area of cannabis production.

Population and samples

A total of 261 cannabis users registered as patients in hospitals. Registered cannabis users in 2014 who settled in Kalasin province, a province chosen randomly from those with the greatest cannabis production in Thailand, were identified as the target population for this study, and were approached to participate in person at an appointment. All 261 agreed and gave their written consent to participate in a study on the burden of disease in April 2015. Of these, 58 cannabis users agreed and gave their written consent to participate in an in-depth study. These individuals gave their private telephone number to the research team and allowed the research team to visit them at home in April 2015. After 1 year, 13 cannabis users moved to other provinces or had lost contact with the research team. Thus, 45 cannabis users remained in April 2016. These 45 individuals lived in 16 communities in 10 districts in Kalasin province.

Besides cannabis users, 16 community leaders were recruited to provide information about community demographics and drug use. In addition, 480 laypeople from 16 communities (30 each of both sexes in various age groups) agreed to answer the Thai Addiction Stigma Scale¹³ (for comparison with the cannabis users). All participants were recruited in April to May 2016.

Tools

In this study, investigators and research assistants were essential. One investigator had a PhD and over 20 years of experience in drug research, one had a PhD and 10 years of experience in drug research, and one had a master’s degree with 5 years of experience in qualitative research. Assistance was provided by health officers who have worked with target communities for over 10 years.

A psychiatric nurse with a master’s degree and over 20 years of experience working with drug addicts, developed three in-depth interview guidelines (for healthcare personnel, community leaders, and cannabis users). Diaries were created for cannabis users to self-report signs/symptoms, healthcare activities, healthcare and related expenditures, and cannabis-related expenditures. The Thai Addiction Stigma Scale (content validity index = 0.97, Cronbach’s alpha = 0.77)¹³ was used to gather data from the laypeople. This scale had a total score ranging from 16 to 120 and comprised 5 subscales: familiarity, risk perception, fear, social distance, and community response. Furthermore, data on burden of disease among cannabis users were gathered using the interview guidelines developed by Loeiyood¹⁴.

Data collection

In April 2015, data on medical history, cannabis use patterns, and personal characteristics were collected from cannabis users though in-depth interviews. A total of 261 cannabis users who gave their consent were interviewed at their home, without anyone else present, after their regular appointment at a hospital. At each appointment, cannabis users provided 30–60 minutes for the research team to interview them. When we did not reach data saturation for a particular participant, we asked participants to take part in another interview at their next appointment and repeated this until the data were saturated (ranging from 1 to 3 times). We did not use voice or video recording or take photographs of the interviews or users. However, notes were taken during the interview. For the 58 cannabis users who consented to the in-depth study, the research team visited them at home for another private interview and participant observation during daily activities on a monthly basis, half a day each. Again, recording devices were not used. Diaries were given to each cannabis user to enable them to record data on the symptoms and expenditures of cannabis use. This diary was exchanged with a researcher once per month based on appointments until April 2016. During the monthly appointments, cannabis users were asked to clarify what they had recorded in the diary and were interviewed in more detail. During the fieldwork period, we interviewed 10 healthcare personnel and 16 community leaders. The Thai Addiction Stigma Scale was administered to the laypeople in early 2016. On cannabis users’ last appointment, around April 2016, they were interviewed about the burden of disease and their medical history in the past year.

Analysis

Data from cannabis users’ diaries and interviews were triangulated with data from the health personnel and community leaders. Content analysis was employed for the interview data, while the health events in the diaries were tallied. To evaluate the burden of disease, we calculated users’ disability-adjusted life years (DALYs) from their 1-year medical history. The direct economic costs, both public (e.g., hospital expenses for – medication, supplies, admission) and private (e.g., food, transportation, and others), of cannabis use were tallied. Furthermore, we calculated the economic losses based on individual non-working hours/days. The costs incurred from other cannabis-related events were also tallied.

Data analysis

Once data were collected from the participants, the researchers used data coding to categorized information. Data analysis was conducted by considering the essence of the content of the health, economic, and social effects of cannabis use in Thailand.

Ethics statement

During the data collection stage, participants provided their written informed consent. Personal identifiers (names, full addresses) were stripped from the dataset. This research project was approved by the Human Research Ethical Committee of Khon Kaen University (HE 571473) based on the principles of the Declaration of Helsinki and the Good Clinical Practice standards of the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH).

Study background and demographic information

The 261 cannabis users we initially selected made 2,698 visits to healthcare facilities in the past 12 months due to illness. Furthermore, 150 out of these 261 users visited the hospital due to cannabis-related illness. Approximately 150 users reported psychiatric problems and 3 experienced multi-drug use. A total of 14 users had road accidents, 6 users were injured by others, and 1 user made a suicide attempt.

Of the 45 participants who completed the in-depth study, all were male and had an average age of 43.51 years. The majority were married (55.53%) and had primary degrees (53.33%), and 37.77% worked as farmers. For most respondents, alcohol was their first drug (53.33%), and they later moved to cannabis. The average age at which participants first used cannabis was 19.02 years. The primary method of cannabis use was bamboo pipes. Participants had used cannabis for an average of 26.86 years. All of them perceived that they were addicted to cannabis. The most common frequency of use was three times per day (42.22%), and the average amount was about 1 g per use.

When researchers followed up with 45 participants after one year, they examined the health, economic, and social effects of cannabis. While none of the users died over the study period, there was a considerable loss of DALYs, at 120.09, with a mean loss of 0.78. Interestingly, among the three users of multiple drugs, cannabis was not the gateway—they had used other drugs before cannabis

Health impacts

Although a number of cannabis users had received treatment for illness over the study year, they generally perceived themselves to be of good health. Of the 45 respondents, 3 reported that they had a preexisting medical condition (one had diabetes and two had epilepsy). One participant told researchers:

“My mother and brother are diabetic. 15 years ago, I went to the hospital and the doctors told me that I was diabetic. An elderly man told me that cannabis can be used to treat diabetes. I tried cannabis and have used it since then. When I went to the hospital last month, the doctors said that I had normal blood sugar.”

Overall, 89.77% of participants viewed themselves as in good health. For example, one respondent said:

“I never get sick. I check on my health every year. I do not have diabetes or blood pressure issues.”

In addition, 87.33% users reported that they did not believe they were abusing drugs, despite their continuous cannabis use. For example, respondents said:

“I can repay everyone. People who use cannabis alone will be healthier. However, if cannabis is used in combination with other drugs like alcohol, then people might be exposed to certain health risks.”

“Most old people in the past, they smoked cannabis, and did not see anyone as crazy or schizophrenic. In contrast, it’s good for smokers...good health and longevity.”

Economic impacts

Of the 45 cannabis users, 17 reported contact with law enforcement since using cannabis is illegal in Thailand. Using data from the self-report diary, we analyzed the private costs of cannabis use, and found that economic losses tended to result from law enforcement—both direct costs (e.g., fines, lawyer fees, transportation) and indirect costs (for both the self and relatives, e.g., production losses, litigation, and accidental losses such as compensation for accident and injury and related costs).

The total medical costs for the cannabis users, including the treatment of addiction, amounted to 142,560 baht (4,537 USD), with an average of 3,168 baht (101 USD) per case. Meanwhile, the total of loss of income, other than prosecution amounted to 32,500 baht (1035 USD), with average of 723 bath (23 USD) per case.

The total costs related to law enforcement and prosecution litigation amounted to 1,445,330 baht (44,267 USD), with an average of 85,019 baht (2,604 USD) per case (range: 12.3–5997.1 USD). Of these total costs, direct costs for litigation (e.g., fines, lawyer fees, bailout) accounted for 1,230,000 baht (39,145 USD), or about 85.1% of all private costs, with an average of 72,353 baht (2,303 USD) per case (range: 0–5,360 USD). The indirect cost accounted for 14.9% of the total costs, and included loss of income during prosecution (82,266 baht or 2,519.6 USD) and caregiver expenses (133,064 baht or 4,075.5 USD), which included transportation/food/accommodation costs during prosecution (102,900 baht or 3,151.6 USD) and loss of caregiver income during prosecution (30,614 baht or 923.9 USD). In addition, the loss of income due to prosecution process was 38,450 baht (1212 USD), an average of 854 baht (27 USD) per case.

Interestingly, we found no costs associated with accidents or property destruction due to drug-related accidents. This may be because when individuals use cannabis, they are careful to keep to themselves or in small groups. Cannabis users do not drive and are often not social while under the influence, as demonstrated by the following responses:

“Since using cannabis, I have never had an accident. I have never heard of anyone using cannabis having an accident. When you smoke cannabis, it puts you in a relaxing, calm mood and you are careful to smoke it by yourself…”

“Do not connect accidents with cannabis use. Cannabis does not cause impulsive moods and thoughts like amphetamines or alcohol.”

Social impact

Social impact in this study was defined as stigma related to cannabis. The 45 cannabis users lived in 16 communities. Within these 16 communities, the addiction stigma score of the 480 laypeople was analyzed. We found a mean stigma score of 84.23 with an SD of 13.44 (95% CI [83.15, 85.31]) and a range of 50 to 111 score. This indicates a moderate level of addiction.

Addiction stigma reflects the negative perception of drug use among community members, and scale scores reflect the degree to which community members attribute various problems in their communities to drug users, including cannabis users. Cannabis users, on the other hand, perceived that cannabis use itself did not cause these social problems, nor did it have an impact on their work or the likelihood of crime, as shown by the following responses:

“I am a hairdresser. Every day, when I smoke cannabis in the morning, I want to do good work and I do it. After work, I smoke in the evening, then go to bed, never disturbing anyone.”

“I have heard rumors that cannabis users are aggressive and assault other people. But no, cannabis puts you in a good mood. I do not want to argue with anyone. It is difficult to find the time to smoke, and it is rare to have a chance to smell the smoke. If you know which family members use cannabis, you will see that these family members do not quarrel. Unless maybe the quarrel was about the use of illegal cannabis, the fear of being arrested, or the fear that others knew they were using drugs.”

“The villagers know who uses cannabis, and they are not offended by it. Cannabis users do not fight and annoy people. But we think that people in the community hate us because it’s illegal. The community thinks that people who use drugs are bad people. The cannabis community has been branded as a drug community . . . if cannabis were legal like cigarettes, the community would not mind. I would not have come to such a dark place.”