A ROLE FOR PHARMACISTS

Since primary health care providers in Canada are hardpressed for time to engage in routine proactive screening, we should consider a role for pharmacies in this regard.

This is not a radical idea. Pharmacies already provide customers with the means to conduct routine blood pressure self-screening. With the right resources at hand, pharmacies could enable self-report screening for risky levels of alcohol and cannabis use.

They could also in turn provide prevention materials, offer brief interventions to facilitate self-change among moderate risk users, encourage individuals to discuss their alcohol or cannabis with primary care providers, or provide contact information for more intensive treatment resources in the community for those screened to be higher risk users.

Pharmacists have been shifting toward a more engaged relationship with their customers as evidenced by the increasing presence of consultation rooms on site.

Governments would of course need to compensate Pharmacists for these services. But the potential savings in down stream costs for relatively low upstream investment, make this an option worth exploring.

ALCOHOL, CANNABIS AND CANCER

I always try to link to professionals in the health promotion and cancer prevention fields. This is because both alcohol and cannabis (if smoked) are carcinogens.

This is the case regardless of whether individuals are dependent (alcoholic, addicted) users or non-dependent users, if they consume in risky levels or ways.

For example, a woman's risk for breast cancer, relative to a non-drinker, increases almost exponentially once she starts having the alcohol content equivalent of more than two 5 oz glasses of wine per day on a regular sustained basis.

From a population perspective the heavy burdens of disease and health system costs from alcohol are associated far more with non-addicted individuals who drink beyond Canada's Lower Risk Drinking Guidelines than with alcoholics. This is simply because the former are such a large portion of the population.

I continue to be perplexed as to why the chronic disease (cancer, stroke, diabetes) prevention community has not become more engaged in addressing risky levels of alcohol use.

This may be a symptom of the misconception still running through the health professions, including medicine, that the only significant problem with alcohol is that it is potentially addictive.

LOOKING BEYOND ADDICTION IN ALCOHOL AND CANNABIS USE

When screening for harmful alcohol or cannabis use, we need to avoid focusing only on addiction.

While both substances are potentially addictive (severe use disorder), it is their respective toxicity and impairment properties that carry by far the larger burden of disease (mortality and morbidity) and overall health costs. Thus screening with tools designed mainly to detect probable addiction can miss the mark by a wide margin.

Whereas indicators of addiction are heavily based on reported loss of use-control and related harms, the much larger group at risk can be identified by routinely asking all adult patients how much they use. This can be done once a year along with other aspects of annual medicals.

In the case of alcohol, we can relate their responses in average number of standard drinks per week to evidence-based lower risk drinking guideline upper thresholds: about 10 standard drinks per week for women and 15 drinks for men.

In the case of cannabis we can minimally ask about frequency of use. Daily or near daily use raises the risks for mental health and other harms.

Patients can then be advised and provided with materials guiding them toward making healthier choices about levels of consumption, as well as urging safer modes of use.

THREE STEPS FOR IMPLEMENTING SCREENING AND INTERVENTION

There are three broad steps we should consider in trying to implement alcohol and cannabis screening and brief intervention (SBI) in Canada.

The major barrier in my view is the intense emphasis on reactive care in our health systems. While we need reactive care to be fully resourced, an exclusively reactive approach keeps us from addressing substance use issues upstream through proactive screening and brief intervention.

It's going to take a lot of time to change our health systems to better balance reactive and proactive care. So that's a long term step that many are already working toward.

As a medium term step we can start expanding our view of health systems to contexts that are already quite proactive and wellness focused. Included here as potential settings for screening and brief intervention are those places where people now go to enhance healthy living: community-based programs like the YW- and YMCA as well as postsecondary and municipal fitness programs.

In the short term, we can provide tools to help individual alcohol and cannabis users reduce their use to lower risk levels partly or wholely on their own. We know that moderate risk users can often cut back without counseling. We can further empower them with well designed resources.