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Accident Compensation Cases

Zxe v Accident Compensation Corporation (DC, 06/10/00)

Judgment Text

Judge A W Middleton
There will be an order that no information which could lead to the identity of the appellant is to be published. Accordingly this judgment will be issued in the name of ZXE. 
The appeal raises four issues being: 
Did the New Zealand Police as second respondent make a proper Application for Review of the first respondent's decision of 13 December 1997. 
Is the appellant entitled to cover for cannabis dependency. 
Is the appellant entitled to cover for post-traumatic stress disorder (PTSD). 
Whether the appellant's incapacity is caused by PTSD and not cannabis dependency, thereby making the appellant ineligible for entitlements under the Act. 
The background which gives rise to the appeal is that the appellant was employed by the second respondent as a Police Officer between September 1985 and December 1994. In June 1990 he applied to join the undercover programme and was accepted after completing the appropriate psychological and medical assessments. He was then referred to the undercover programme for the appropriate training to enable him to become part of that programme. The appellant was then involved in an undercover deployment between 3 September 1990 and 4 September 1991, with a focus on drug enforcement in the city to which he had been deployed. Following that deployment he was involved in the usual debriefing programme and assisted with training new operatives. In accordance with the standard procedure the appellant was referred by the second respondent to its Consultant Psychiatrist, Dr A D McLeod, and subsequently to his successor, Professor J Bushnell. He also had access to the Police Chief Medical Advisor, Dr MacDonald, and its Psychologist, Dr I Millar. 
The second respondent advised that the appellant undertook scheduled consultation with the various professionals during the period of his deployment. Records of Professor Bushnell's notes made during the period while the appellant was undercover and subsequently, are on the file. On 19 March 1991 his note records: 
“THC minimal. ”
On 10 June 1991 Professor Bushnell noted that the appellant was “emotionally tired”, and that“operation going well, sleeps well”, and that the appellant's “alcohol, THC, cigarettes under control, consumption reducing.” 
On completion of his deployment the appellant underwent medical testing and psychological assessment, and on 17 September 1991 the Police medical review certified the appellant as fit for full duties. At the same time the appellant completed his triennial medical questionnaire in which he confirmed that his health was “fair”
On 20 September 1991 the appellant underwent a full medical examination including x-rays, liver function and cardio-vascular function tests. This was a similar examination to the one the appellant had undertaken prior to being deployed in the undercover work. The result of the cardio-vascular function test was “middle of excellent.” 
On 22 September 1991 the appellant was referred by the second respondent to Dr T N Crutchley who reported that his liver function tests were elevated and that he should undergo a repeat test with a general practitioner at the expiration of six weeks. Dr Crutchley reported that an x-ray of the appellant's chest confirmed no abnormality. Dr Crutchley had obtained the x-rays because the appellant had advised him that his level of cigarette smoking and other substances had increased dramatically while he was deployed. Following completion of those tests the appellant then returned to regular Police work from September 1991. 
On 18 October 1994 the appellant made an application under s 28D of the Police Act 1958 to disengage from the New Zealand Police. In his application the appellant gave as his reasons: 
Detail Reasons for the Application and Include: 
Any medical, physical and/or psychological conditions: Experience stress related difficulties affecting physical health and well being. 
Detail any treatment received: Counselling from doctors and psychologist. 
To whom within the Police the condition was first reported: (Time, date, place, etc): Greg Ford, Regional Psychologist, Auckland Police Welfare, July 1994. 
Duties (if any) able to be performed despite any medical physical or psychological conditions: Unable to perform any police related duties. 
Any specific incident that has led to the application: Deployment in Undercover duties 1990/1991. ’”
In support of the appellant's application for disengagement he provided a certification from a General Practitioner whose diagnosis was that the appellant suffered: 
“Occupational maladjustment. He is no longer prepared to accept police authority. Has no pride or satisfaction in working for police. Decreased self esteem. Has anger and resentment towards the force and fellow police officers. ”
The GP concluded that the appellant's incapacity was due to his inability to meet the relevant standards of “psychological” health. The appellant was referred to Mr D Carter, a Clinical Psychologist, whose report of 30 November 1994 stated: 
“He considers that after his time undercover he realised that the job of a member of the NZ Police had changed considerably, and that he as an individual had likewise changed a great deal. In his view, ZXE considers that together this has resulted in his becoming directless, and eventually unable to function as a policeman. 
In ZXE's view, policing has significantly changed in the last four to five years. He relates a long list of grievances about current police agendas, the constraints now placed upon the behaviour of the police and the perceived inadequacies of the Justice system. As he sees it, the attitude of the police has changed, such that he does not any longer fit in. ZXE considers that while his views have widened a great deal, the general police attitude has become more and more narrow. 
ZXE is aware that in the initial period of his return to normal police duties he was very paranoid, both toward the public and to other police members. He says that he has endeavoured to deal with this by keeping very much to himself. However, this appears to have led to him becoming more and more isolated, very analytic about himself, his childhood and his current difficulties, and depressed. 
Since coming out of the under cover programme he has found it increasingly difficult to relate to ordinary policing and has felt ‘like a fish out of water’ with other police and ‘very lonely’. It appears that although he considers his views have widened, his activities appear to have become very narrow. He has no outside interests, no serious relationships. He considers his time has been fully occupied in simply endeavouring to ‘cope with the job’
It is my opinion that ZXE has been struggling with a depressed mood since returning to usual police duties. This appears to have worsened slowly over recent months. However, I think that the features of this depression do not meet the criteria for a specific mood disorder. Rather, the appropriate diagnosis is 
Depressive Disorder, NOS 
(NOS-111-R. 311.00 
This disorder is such that it precludes ZXE from effectively performing the duties which he may reasonably be called upon to perform as a member of the New Zealand Police. I am sure he will be able to function effectively in some alternative employment. ”
The appellant then lodged a claim for cover with the first respondent on 1 April 1996. His explanation of how his injury was caused was “Prolonged exposure to hazardous work environment (intoxicating chemicals).” His General Practitioner gave the diagnosis “Employment related cognitive dysfunction.” The appellant completed an application for entitlement to cover with the first respondent on 18 June 1997 in which he stated that the cause of the injury was “drug & alcohol consumption, cannabis alcohol use, stress arising from psychological working conditions.” 
On 22 July 1997 following a request for further information, the GP reported the diagnosis as: 
“Drug dependence, marijuana with secondary depression and apathetic amotivation syndrome. There are no other problems known. ”
The first respondent then requested the appellant to complete the Gradual Process Claimant Questionnaire form which is dated 6 October 1997. In answer to the question “What were your first symptoms or problems?” the appellant's answer was, 
“During the operation I suffered some physical side effects but it was only some time after completion of the assignment that I perceived that I indeed had a dependency problem. ”
In answer to the question “When did you first notice that?” the answer was, 
“First noticed or acknowledged dependency only after task completed. ”
The first respondent then referred the appellant to Dr G Cliff, a Consultant Psychiatrist, whose report of 21 November 1997 recorded: 
“The stress of the covert work was enormous: physically, because of the disorganized lifestyle which entailed irregular hours of sleep and disorganized eating habits, but more particularly mentally because of the ever-present risk of discovery and resultant injury or even death. ”
Later in his report Dr Cliff noted: 
“It must be emphasized, that prior to his joining the undercover programme, ZXE was in excellent mental health. He had no history of any psychological disorder or condition, and was evidently in all respects a well adjusted individual. 
During the course of his deployment he learned to be always vigilant, suspicious to the point of paranoia, socially aloof despite superficial friendliness, and above all else to be anxious. ”
In regard to his psychological health Dr Cliff noted: 
“His life remains dominated by the pursuit of cannabinoid drugs. Much to his dismay, his use seems to be increasing steadily; he smokes cannabis several times a day, his consumption being limited only by the availability of supply and his financial resources. He estimates that he smokes on average a third of an ounce weekly, at a cost of between $250 and $400. ”
Dr Cliff's opinion was: 
“It is, in my opinion, quite clear that ZXE suffers from the following psychiatric conditions: 
Cannabis dependence (DSM-IV 304.30; ICD-10 F12.24
This is characterized by a compulsion to obtain and use the drug, with repeated self-administration that has resulted in tolerance, withdrawal symptoms when the drug is not used, and is complicated by cognitive, behavioural and physiological symptoms. 
Chronic post-traumatic stress disorder (PTSD) (DSM-IV 309.81; ICD-10 F43.1
This is characterized by the following — 
recurrent re-experiencing of the original stressor(s) both in wakefulness and in sleep; 
(vain) efforts to avoid thoughts, feelings, activities etc. reminiscent of the stressor(s); 
a marked diminution in interest/participation in significant activities; 
a feeling of social alienation; 
a sense of foreshortened future/futility; 
restricted range of affect; 
sleep disturbance; 
irritability/outbursts of anger; 
an exaggerated startle response. 
It is further my opinion that both of these conditions are directly attributable to his former employment as an undercover Police Officer. I attribute this to gradual process in the course of his employment, so that during the undercover period September 1990 — September 1991 he was exposed to such extreme stress that he rapidly developed a chronic, enduring pathological state; and he also developed habitual cannabis use which transmuted in time into true drug dependence. 
Furthermore, in my opinion he suffered personal injury not only by way of mental stress, but also physical stress; well recognized and consistently observed physical effects of chronic cannabis smoking have included bronchitis, pharyngolaryngitis, adverse effects on heart muscle and blood pressure, the suppression of immune responses and anti-bacterial defence mechanisms, and the risk of cancer (marijuana cigarettes contain far more tar (particulates) and respiratory irritants than tobacco). In this regard, I have taken account of his heavy tobacco usage too, but the effect of the cannabis can not, in my opinion, be disregarded because of this. 
The physical injury due to PTSD relates to changes in blood pressure, muscle tension, hormonal alterations, immune system changes as well as the neurochemical dysfunction underlying the psychological processes. ”
On receipt of that opinion the first respondent notified the appellant on 15 December 1997 that it considered that he had established that he suffered a cannabis addiction as a result of his employment as an undercover policeman, and that in terms of s 7(1) he was entitled to cover under the Act. However the letter went on to state that the first respondent considered that his incapacity for work was the result of Post Traumatic Stress Disorder, which was not compensatable under the Act as he had not suffered a physical injury. As a result the appellant had no entitlements under the Act. 
A similar notification was sent to the second respondent as the appellant's employer. 
On 19 December 1997 the second respondent replied to the first respondent: 
“Thank you for your letter of 15 December. 
This letter is to formally advise you that NZ Police will seek a review of the Corporation's decision and ask that you forward the relevant documentation direct to this office. 
We also ask for full disclosure of ZXE's claim, which of course includes all medical reports to be considered by the Review Officer. ”
The appellant also applied for a review of the first respondent's decision. At the review hearing the appellant's counsel raised the issue that the second respondent's Application for Review was not a valid application in terms of s 87(2) of the Act. The Review Officer concluded that the application clearly confirmed the applicant's dissatisfaction with the first respondent's decision, and that it constituted a sufficient Application for Review. She concluded that the issue of how specific the application should be was not relevant to the issue before her as it appeared that all parties were well aware of the second respondent's notification of its intention to apply for a review because it did not accept the first respondent's decision, and that by the time the issue came before the Review Officer all parties were well aware of the issues. She concluded that as a matter of natural justice the Application for Review by the second respondent was a valid application. 
The Review Officer found on the evidence, supported by the decision in CBA 25/98 that the smoking of cannabis on certain occasions as an undercover agent does have a property or characteristic which may contribute to the development of cannabis dependency. She concluded that on the evidence that cannabis dependency was not diagnosed until some time after he left the undercover role, and that the evidence established that it was present to a material extent in the appellant's non-employment activities. The appellant had not satisfied the requirements of s 7(1)(b). 
The Review Officer also concluded that the diagnosis of PTSD had not arisen from physical stress and could, therefore, not be accepted as a personal injury. The Review Officer concluded that the appellant's Application for Review was unsuccessful on both the issues of cannabis dependency and Post-Traumatic Stress Disorder. It is against that decision which the appellant now appeals. 
In support of his appeal the appellant provided a full affidavit in relation to the history of events which led to his claim. The appellant was given leave to adduce a further report from Dr Cliff which is dated 7 October 1998. In that report Dr Cliff gave as his opinion: 
“I shall divide this into two parts: 
Firstly, a re-statement of my diagnoses of his conditions, and a justification thereof; secondly, a critique of submissions made by the Police at ACC Review, and of the Review Officer's own conclusions. 
In my opinion, ZXE continues to suffer from two discrete but interactive psychiatric conditions, viz: 
cannabis dependency 
chronic post-traumatic stress disorder (PTSD). 
For the sake of consistency and convenience I shall use the diagnostic system set-out in the Diagnostic and Statistical Manual of Psychiatric Disorders, fourth edition (DSM-IV) published by the American Psychiatric Association, 1994. There are other internationally accepted diagnostic schedules, but this particular one is commonly used throughout New Zealand. 
Cannabis Dependence: 
In the DSM-IV this is subsumed under the general group of Substance Related Disorders; in this, Substance Dependence is defined as follows: 
A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12 month period: 
tolerance, as defined by either of the following: 
a need for markedly increased amounts of the substance to achieve intoxication or desired effect 
markedly diminished effect with continued use of the same amount of the substance 
withdrawal, as manifested by either of the following: 
the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for withdrawal from the specific substances) 
the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms 
the substance is often taken in larger amounts or over a longer period than was intended 
there is a persistent desire or unsuccessful efforts to cut down or control substance use 
a great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its effects 
important social, occupational or recreational activities are given up or reduced because of substance use 
the substance us is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption) 
Specify if: 
With Physiological Dependence: evidence of tolerance or withdrawal (i.e. either Item 1 or 2 is present). 
Without Physiological Dependence: no evidence of tolerance or withdrawal (i.e., neither Item 1 nor 2 is present). 
From my original report, confirmed by this latest examination, you will see that ZXE's condition does satisfy the diagnostic criteria of Substance Dependence, with specific reference to cannabis. 
To take it point-by-point: 
He has tolerance, in that his use of the drug has steadily increased over time (p.4, para (b), line 2 of my original report); 
He has experienced withdrawal effects characterized by physical and mental symptoms on account of which he has had to continue using the drug (p.4, para (b), lines 5 — 8 of my original report); 
he has unsuccessfully tried to cut down/control the use of cannabis (ibid.); 
he has spent a great deal of time in activities necessary to obtain the cannabis (p.4, para (b), line 1 of my original report). 
It is furthermore the case that ZXE had at the latest examination confirmed his knowledge that smoking cannabis is bad for him, both physically and mentally, and yet he has felt compelled to continue using it. 
You will also deduce from his symptoms and the diagnostic criteria that ZXE has physiological, as well as psychological dependence on cannabis. 
I would further add that the use of cannabis has been hazardous to his health not only in terms of physiological and psychological dependence, but also because cannabis smoke contains a high level of toxins (far greater than that contained in tobacco smoke) which can damage not only respiratory tissue but also exert adverse effects on diverse bodily functions such as the immunological system and reproductive capability. Moreover, the substances contained in cannabis smoke are known to be potent carcinogens. 
Post-traumatic Stress Disorder: 
The diagnostic criteria for PTSD, as set out in DSM-IV are as follows: 
The person has been exposed to a traumatic event in which both of the following were present: 
the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others 
the person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behaviour. 
The traumatic event is persistently re-experienced in one (or more) of the following ways: 
recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed 
recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content 
acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: In young children, trauma-specific re-enactment may occur 
intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event 
physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. 
Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following: 
efforts to avoid thoughts, feelings, or conversations associated with the trauma 
efforts to avoid activities, places or people that arouse recollections of the trauma 
inability to recall an important aspect of the trauma 
markedly diminished interest or participation in significant activities 
feeling of detachment or estrangement from others 
restricted range of affect (e.g., unable to have loving feelings) 
sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span). 
Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following: 
difficulty falling or staying asleep 
irritability or outbursts of anger 
difficulty concentrating 
exaggerated startle response. 
Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month. 
The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. 
Specify if: 
Acute: if duration of symptoms is less than 3 months 
Chronic: if duration of symptoms is 3 months or more 
Specify if: 
With Delayed Onset: if onset of symptoms is at least 6 months after the stressor. 
In keeping with those criteria, ZXE suffers/exhibits the following symptoms: 
He continues to suffer from recurrent and intrusive, distressing recollections of the emotional trauma related to his undercover deployment; 
he furthermore has recurrent distressing dreams on the same theme. 
he consciously tries to avoid thoughts, feelings or conversations associated with this subject because they are so distressing; 
he similarly goes out of his way to avoid activities, places or people that arouse recollections of this emotional trauma; 
he has an enduring and profound feeling of detachment/estrangement from others. 
he has persistent symptoms of increased arousal, including insomnia, hyper-vigilance, difficulty concentrating, irritability and labile mood. 
It is simply impossible, in my view, to neatly attribute aspects of ZXE's disability to cannabis dependence on the one hand, and PTSD on the other. The processes are interactive, and may indeed symptomatically contribute to varying degrees at different times. It can not therefore, in my opinion, be contended that the principal cause of his dysfunction — especially his employment disability — is due to PTSD rather than his drug dependence. 
From a practical point of view, he must be taken as a whole individual, whose impairment derives from two conditions which in turn originated in the same source — viz. his deployment as an undercover Police Officer. To my mind, the only reasonable and practical application of the law as it stands, in the acknowledgement of natural justice, should be in such practical terms rather than esoteric debate as to exactly which little bit of his disorder is attributable to which particular cause. The fact of the matter is that ZXE's life was wrecked by his deployment in deep cover, and remains that way; he may one day recover sufficiently to be able to resume a semblance of normal living but in the meantime he is suffering physically and mentally as a direct consequence of his previous employment. ”
The appellant was given leave to adduce three additional reports from Professor Bushnell. The first, on 20 April 1999, states: 
“To summarise my contact with ZXE, he was seen every three months during his deployment, and six-monthly for the subsequent two years. I took over from Dr McLeod near the end of ZXE's time working undercover. ZXE was, as Dr McLeod had observed, an intense young man, who was rather guarded about what he disclosed, and did not admit to any emotional problems even though his long-term relationship had ended during his deployment and he was drinking heavily. He described only moderate cannabis use, and I was more concerned about his alcohol intake during and immediately after his deployment. This settled during the first few months back in uniform, and after some adjustment difficulties in the first six months ZXE appeared to be adjusting well to normal life. He had good reports from his superior officers, and during the final 18 months of post-deployment monitoring described having his use of alcohol and cannabis under control. Although he continued to smoke cannabis occasionally he did not see this as a problem, apart from the risk inherent in doing so whilst being a Police Officer. 
I saw ZXE occasionally during the next two years, during which time he seemed to be coping well. Then in mid-August 1994, he came to see me and disclosed that he was unhappy continuing to work for the Police, and found the attitudes of his senior colleagues in particular to be hypocritical and frequently missing the point. He disclosed then that he had been smoking cannabis more heavily than he had admitted ever since his deployment had ended, and he felt that this had contributed to a growing sense of isolation and alienation from his fellow Police Officers. We met again about three weeks later, and traversed much of the same territory, and discussed options for him to get psychological support if he was to return to the area. 
I have no doubt that the experience of working undercover was profoundly unsettling for ZXE. Living a role in which one ‘switches sides’ challenges the prevailing view prevalent within police circles that there is a ‘them’ and an ‘us’, so that many undercover officers feel out of place when they return to regular duties. ZXE's cautious attitude to disclosing anything about what was troubling him meant that there was no opportunity to intervene psychologically until it was too late, and he had reached a point of no return in his decision to leave the police. ”
Then in a further report on 27 April Professor Bushnell stated: 
“In response to your specific questions: 
ZXE said nothing to me which lead [sic] me to believe that he had been untruthful about his use of cannabis during his period of deployment as an undercover agent. The focus of his concern was mainly on the difficulties he was experiencing following his return to normal duties. 
The term THC in my notes and those of Dr MacLeod refers to Tetra-Hydro-Cannabinol, which is the main psychoactive ingredient in Cannabis. 
I am not in a position to make a judgment on the facts of what occurred during ZXE's deployment as an undercover agent. He did not disclose more than the limited use of cannabis (occasionally sharing a joint with associates) which was consistent with maintaining his undercover role. 
You (or other health practitioners) may have information I do not know about. I have not heard any evidence from ZXE that would lead me to the conclusion that he was dependent upon cannabis. The diagnostic system current when ZXE was deployed was one called ‘DSM-IIIR’. To meet a DSM-IIIR cannabis dependence diagnosis he would have daily or almost daily use of cannabis, and he would have to have persisting or recurrent experience of at least three of a list of symptoms including: increasing intake or growing duration of use; persistent desire or unsuccessful attempts to reduce intake; spending a great deal of time in acquiring, using and recovering from the drug; frequent intoxication interfering with major role obligations; reduction in important social, occupational and recreational activities because of using cannabis; continued use despite knowing that a recurrent social, psychological or physical problem is exacerbated by cannabis use; marked tolerance (need for increasing amounts of cannabis to get ‘stoned’); and use of cannabis to relieve or avoid withdrawal symptoms. 
My understanding was that ZXE's use was intermittent and associated with stress release, had not escalated in intensity, was not associated with a desire to cut down or control use, and although risky by virtue of the fact that he was a police officer, did not interfere with his social or occupational functioning. 
Throughout the time I knew ZXE he appeared to settle back into his role as a policeman and be working productively. After a few teething problems when he initially found the restrictions of authority and the formalities of procedures frustrating, ZXE himself reported feeling that life was back on track and that although his perspective on life had changed, he was satisfied with how things were progressing. Throughout the time post-deployment during which I had contact with ZXE, he described occasional social use of cannabis which he said was not a problem, and was under control. Even in 1994 when we discussed ZXE's intention to leave the Police, and he described heavier cannabis use than previously, his concerns were mainly about his frustrations with the job and his sense of not fitting in to a job dominated by ‘pen-pushers’ who did not seem to value real police work of being ‘out there catching criminals’. That is, his decision seemed to be mainly about his views of police functioning, and his sense of no longer fitting in. 
I have no doubt that ZXE's exposure to working undercover has contributed to his dissatisfaction with his career, and that his decision to leave his career could be seen as evidence of a failure of rehabilitation in spite of the measures put in place to facilitate this process. However on the basis of the information I have, I do not believe that cannabis dependency is the central issue here: rather the particular combination of ZXE's coping style, and the circumstances in which he was working have come together to profoundly unsettle him and his understanding of the world. As a result, he felt that he no longer fitted in to the niche in life that he left in order to work undercover, and this was the primary driving force behind his decision to leave his job. ”
In response to further questions put to him by the appellant's counsel, Professor Bushnell replied on 1 July 1999: 
The question is confused. DSM-III criteria relate to the presence of a syndrome which results from heavy, sustained cannabis use. The manner of determining the presence of that syndrome is to ask the person about their use of cannabis and the consequences they experience as a result of that use. ZXE described a pattern of occasional social use of cannabis which he could ‘take or leave’. As I indicated in my letter of 27 April, ZXE had stated that his use of cannabis was intermittent and associated with stress release, and did not escalate in intensity over time, was not associated with any sense of difficulty controlling use, and did not interfere with his social or occupational functioning. 

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