Cannabis as a substitute for alcohol and other drugs

"Everything is kind of the same except my mind is with me": exploring cannabis substitution in a sample of adults in early recovery from an opioid or stimulant addiction

BACKGROUND

Recovery from addiction is frequently equated with abstinence. However, some individuals who resolve an addiction continue to use substances, including via substitution (i.e., increased use of one substance after eliminating/ reducing another). Substitution may play a distinct role during early recovery (≤ 1 year), as this period is marked by dramatic change and adjustment. Cannabis is one of the most used substances and is legal for medical and recreational use in an increasing number of states. Consequently, cannabis an increasingly accessible substitute for substances, like fentanyl, heroin, cocaine and methamphetamine, with higher risk profiles (e.g., associated with risk for withdrawal, overdose, and incarceration).

METHODS

Fourteen participants reported that they had resolved a primary opioid or stimulant addiction and subsequently increased their cannabis use within the previous 12 months. Using grounded theory, the interviewer explored their experiences of cannabis use during early recovery. Data were analyzed in three stages: line by line coding for all text related to cannabis use and recovery, focused coding, and axial coding to generate a theory about recovery with cannabis substitution. The motivational model of substance use provided sensitizing concepts.

RESULTS & DISCUSSION

The final sample included eight men and six women ranging in age from 20 to 50 years old. Three participants resolved an addiction to methamphetamine and the remaining 11, an addiction to opioids. Participants explained that cannabis was appealing because of its less harmful profile (e.g., no overdose risk, safe supply, few side effects). Participants' primary motives for cannabis use included mitigation of psychiatric symptoms, withdrawal/ cravings, and boredom. While cannabis was effective toward these ends, participants also reported some negative side effects (e.g., decreased productivity, social anxiety). All participants described typical benefits of recovery (e.g., improved self-concept, better relationships) while continuing to use cannabis. Their experiences with and beliefs about substitution suggest it can be an effective strategy for some individuals during early recovery.

CONCLUSIONS

Cannabis use may benefit some adults who are reducing their opioid or stimulant use, especially during early recovery. The addiction field's focus on abstinence has limited our knowledge about non-abstinent recovery. Longitudinal studies are needed to understand the nature of substitution and its impact on recovery over time.

Medical marijuana laws and mental health in the United States

The consequences of legal access to medical marijuana for individuals' well-being are controversially assessed. We contribute to the discussion by evaluating the impact of the introduction of medical marijuana laws across US states on self-reported mental health considering different motives for cannabis consumption. Our analysis is based on BRFSS survey data from close to eight million respondents between 1993 and 2018 that we combine with information from the NSDUH to estimate individual consumption propensities. We find that eased access to marijuana through medical marijuana laws reduce the reported number of days with poor mental health for individuals with a high propensity to consume marijuana for medical purposes and for those individuals who likely suffer from frequent pain.

Cannabis and Public Health: A Study Assessing Regular Cannabis Users Through Health Indicators

Background and Objective: An increasing number of countries are deciding to regulate the medicinal and/or recreational use of cannabis (Cannabis sativa L.). However, there is a lack of information on the impact of regular consumption of this substance on public health. In this study, for the first time, regular cannabis consumers in Spain were assessed using health indicators, comparing these data with the general population. Methods: Various items of the Enquesta de Salut de Catalunya (ESCA) and other items related to cannabis use were selected to build a survey and administer it to a representative sample of regular cannabis users in Catalonia. Results: Most of the indicators did not show any deterioration in the health of regular cannabis users compared with the general population. It was observed that users suffered from more sleep problems and about 40% of the sample would like to discontinue cannabis use, suggesting a dependence pattern. About 30% of the sample was able to discontinue the use of prescription medications because of cannabis. Social support and sleep problems, and not cannabis use, were predictors of depression and well-being scores. Conclusions: It seems that regular cannabis use, despite contributing to problems related to sleep quality or dependence, does not have a negative impact on public health in a manner detectable using health indicators.

Does cannabis use substitute for opioids? A preliminary exploratory survey in opioid maintenance patients

Various studies showed that people with substance use disorder use cannabis to reduce withdrawal or dose of their main drug. Using a questionnaire about their cannabis use, 118 participants in an opioid maintenance treatment (OMT) in Germany were examined regarding this strategy. 60% reported to use cannabis. Of those, 72% were using cannabis in the suggested way. Cannabis was used to substitute for, e.g., heroin (44.8%) and benzodiazepines (16.4%). We also asked for an estimation of how good cannabis was able to substitute for several substances (in German school grades (1 till 6)); heroin average grade: 2.6 ± 1.49. Besides that we asked about the idea of cannabis as "self-medication", e.g., to reduce pain (47%) and about negative consequences from cannabis use. Our results suggest to consider the use of cannabis by patients in OMT rather as a harm reduction strategy to reduce the intake of more dangerous drugs.

Cannabis donation as a harm reduction strategy: a case study

BACKGROUND

The United States (US) continues to experience unprecedented rates of overdose mortality and there is increased need to identify effective harm reduction practices. Research from Canada describes cannabis donation through harm reduction agencies as an adjunctive strategy to mitigate the negative consequences of more harmful drugs. This case study describes the operational logistics, feasibility, and potential benefits of a cannabis donation program that was operated through a harm reduction program in rural Michigan.

CASE PRESENTATION

We applied a community driven research approach to gather information from harm reduction program staff about the implementation and evolution of cannabis donation efforts in Michigan. We also examined 20-months (September 2021 through May 2023) of administrative data from a cannabis company to compare the sale and donation of cannabis products. Ten cannabis-experienced harm reduction clients received cannabis donations, with clinical staff determining client interest and appropriateness, and providing weekly pick-up or delivery. To expand product availability and sustainability, we examined administrative data from a commercialcannabis company that volunteered to provide donations. This administrative data suggests that while flower products constitute most of the adult and medical sales, edible, oil, and topical products predominated donations. Further, cost analysis suggests that donations represent only 1% of total gross sales and account for much less than the expected yearly donation amount.

CONCLUSIONS

Research suggests there is potential to reduce alcohol and drug use related harms of more dangerous substances through substitution with cannabis. This case study is the first to document cannabis donation as a harm reduction practice in the US and suggests potential for sustainability dependent on state laws. Findings from this case study provide a starting point for inquiry into cannabis donation as a harm reduction strategy in the US; future research is needed to fully understand the individual-level outcomes, public health impacts, necessary legal regulations, and best practices for cannabis donation programs through harm reduction organizations.

Test-retest reliability of DSM-5 substance use symptom checklists used in primary care and mental health care settings

INTRODUCTION

Substance use disorders (SUDs) are underdiagnosed in healthcare settings. The Substance Use Symptom Checklist (SUSC) is a practical, patient-report questionnaire that has been used to assess SUD symptoms based on Diagnostic and Statistical Manual of Mental Disorders-5th edition (DSM-5) criteria. This study evaluates the test-retest reliability of SUSCs completed in primary and mental health care settings.

METHODS

We identified 1194 patients who completed two SUSCs 1-21 days apart as part of routine care after reporting daily cannabis use and/or any past-year other drug use on behavioral health screens. Test-retest reliability of SUSC scores was evaluated within the full sample, subsamples who completed both checklists in primary care (n=451) or mental health clinics (n=512) where SUSC implementation differed, and subgroups defined by sex, insurance status, age, and substance use reported on behavioral health screens.

RESULTS

In the full sample, test-retest reliability was high for indices reflecting the number of SUD symptoms endorsed (ICC=0.75, 95% CI:0.72-0.77) and DSM-5 SUD severity (kappa=0.72, 95% CI:0.69-0.75). These reliability estimates were higher in primary care (ICC=0.81, 95% CI:0.77-0.84; kappa=0.79, 95% CI:0.75-0.82, respectively) than in mental health clinics (ICC=0.74, 95% CI:0.70-0.78; kappa=0.73, 95% CI:0.68-0.77). Reliability differed by age and substance use reported on behavioral health screens, but not by sex or insurance status.

CONCLUSIONS

The SUSC has good-to-excellent test-retest reliability when completed as part of routine primary or mental health care. Symptom checklists can reliably measure symptoms consistent with DSM-5 SUD criteria, which may aid SUD-related care in primary care and mental health settings.

Simultaneous Cannabis and Alcohol Use among Medical Cannabis Patients

Background: During the past two decades of cannabis legalization, the prevalence of medical cannabis (MC) use has increased and there has also been an upward trend in alcohol consumption. As less restricted cannabis laws generate more adult cannabis users, there is concern that more individuals may be simultaneously using medical cannabis with alcohol. A few studies have examined simultaneous use of medical cannabis with alcohol, but none of those studies also assessed patients' current or previous non-medical cannabis use. This paper explores simultaneous alcohol and medical cannabis use among medical cannabis patients with a specific focus on previous history of cannabis use and current non-medical cannabis use. Methods: A retrospective cohort study of MC patients (N = 319) from four dispensaries located in New York. Bivariate chi-square tests and multivariable logistic regression are used to estimate the extent to which sociodemographic and other factors were associated with simultaneous use. Results: Approximately 29% of the sample engaged in simultaneous use and a large share of these users report previous (44%) or current (66%) use of cannabis for non-medical purposes. MC patients who either previously or currently use cannabis non-medicinally, men, and patients using MC to treat a pain-related condition, were significantly more likely to report simultaneous alcohol/MC use. Conclusions: Findings indicate that there may be differential risks related to alcohol/MC use, which should be considered by cannabis regulatory policies and prevention/treatment programs. If patients are using cannabis and/or alcohol to manage pain, clinicians should screen for both alcohol and cannabis use risk factors.

Translating the lived experience of illicit drinkers into program guidance for cannabis substitution: Experiences from the Canadian Managed Alcohol Program Study

A small but growing body of research has suggested the potential for cannabis substitution to support Managed Alcohol Program (MAP) service users to reduce acute and chronic alcohol-related harms. In 2022, researchers from the Canadian Managed Alcohol Program Study (CMAPS) noted a dearth of accessible, alcohol-specific educational resources to support service users and program staff to implement cannabis substitution pilots at several MAP sites in Canada. In this essay, we draw on over 10-years of collaboration between CMAPS, and organizations of people with lived experience (the Eastside Illicit Drinkers Group for Education (EIDGE) and SOLID Victoria) to describe our experiences co-creating cannabis education resources where none existed to support MAP sites interested in beginning to provide cannabis to participants. The research team relied on the unique lived experiences and informal cannabis-related harm reduction strategies described by EIDGE and SOLID members to create cannabis education resources that were accurate and relevant to MAP sites. EIDGE was familiar with creating peer-oriented educational resources and convened meetings and focus groups to engage peers. CMAPS research team members created standard cannabis unit equivalencies to support program delivery, and clinical advisors ensured that the stated risks and benefits of cannabis substitution, as well as tapering guidance for withdrawal management, were safe and feasible. The collaboration ultimately produced tailored client-facing and provider-facing resources. Our experience demonstrates that the lived expertise of drinkers can play an integral role in creating alcohol harm reduction informational materials, specifically those related to cannabis substitution, when combined with data from rigorous, community-based programs of research like CMAPS. We close by listing additional considerations for cannabis substitution program design for MAP settings emerging from this process of collaboration between illicit drinkers, service providers, clinicians, and researchers for consideration by other programs.

Alcohol protective behavioral strategies for young adults: a content analysis across drinking contexts and gender

Background: Protective behavioral strategies (PBS) are specific harm reduction behaviors which mitigate alcohol-related consequences among young adults. Prior work indicates PBS utilization varies according to drinking context and gender, suggesting a need for further research assessing whether young adults employ unidentified PBS according to such factors.Objectives: This study examined alcohol PBS young adults suggest using across drinking contexts and gender to inform alcohol-related harm reduction interventions.Methods: An online survey with 514 young adult heavy drinkers (n = 269 female, Mage = 22.36 years) assessed PBS use generally, and across 12 physical and social contexts. We utilized qualitative content analysis methods to code and derive themes from open-ended responses from a prompt asking participants to state additional PBS used per context. The frequency of each theme's appearance was calculated across the overall sample, by gender, and within each context.Results: PBS endorsement varied across context and gender within each theme. Young adults who reported PBS use most frequently endorsed utilizing strategies related to drink content (18.30%), social support (12.36%), and engaging in other activities (10.34%). Participants infrequently endorsed strategies related to awareness of time (0.23%), standards of behavior (0.78%) and avoiding environments (0.87%).Conclusions: Young adults endorse utilizing additional PBS in varying frequency according to drinking context and gender. Given PBS are often a key component of alcohol harm reduction interventions, monitoring trends in young adult PBS use is crucial to ensure continued relevance and efficacy of such interventions to minimize harms associated with young adult heavy alcohol use.

Evaluating substance use outcomes of recreational cannabis legalization using a unique co-twin control design

Background: As more states pass recreational cannabis legalization (RCL), we must understand how RCL affects substance use.Objectives: The current study aims to examine the effect of RCL on lifetime and past-year use of cannabis, alcohol, tobacco, and other drugs, frequency of cannabis, alcohol, and tobacco use, co-use of cannabis with alcohol and tobacco, and consequences from cannabis and alcohol use.Methods: We used a unique, co-twin control design of twin pairs who were discordant for living in a state with RCL between 2018 and 2021. The sample consisted of 3,830 adult twins (41% male), including 232 twin pairs discordant for RCL. Problems from alcohol and cannabis use were assessed via the Brief Marijuana Consequences Questionnaire and the Brief Young Adult Alcohol Consequences Questionnaire.Results: Results indicated that the twin living in an RCL state was more likely to endorse past-year cannabis use (OR = 1.56, p = .009), greater number of cannabis use days in the past 6 months (β = 0.47, p = .019), but not more negative consequences from cannabis use (β = 0.21, p = .456) compared to their co-twin in a non-RCL state. There were no differences within-twin pairs in frequency of alcohol use (β=-0.05, p = .601), but the RCL twin reported fewer negative consequences from alcohol use (β=-0.29, p = .016) compared to their co-twin in a non-RCL state. We did not observe any other differences within-twin pairs on other outcomes.Conclusion: These results suggest that living in an RCL state is associated with greater cannabis frequency but not more negative consequences from cannabis use than living in a non-RCL state.

Exclusive Therapeutic Use of Cannabis in a Large Sample of Daily Cannabis Users in France: A Cross-Sectional Survey

Many cannabis users report therapeutic benefits from cannabis consumption, even when not recommended by a physician. To date, few data on therapeutic users of cannabis in France are available. Using a cross-sectional survey held in 2020, we collected sociodemographic, health and substance use data from 4150 daily cannabis users in France. We used multivariable logistic regression to assess factors associated with exclusive therapeutic use of cannabis. Approximately 10% (n = 453) of the participants reported using cannabis exclusively for therapeutic purposes. Exclusive therapeutic users of cannabis differed from non-exclusive (i.e. recreational and mixed) users, especially regarding age (aOR [95%CI] = 1.01 [1.00-1.02]), employment (aOR = 0.61 [0.47-0.79]), urban area of residence (aOR = 0.75 [0.60-0.94]), physical (aOR = 2.95 [2.34-3.70]) and mental health condition (aOR = 2.63 [1.99-3.49]), mode of cannabis administration (non-smoked, aOR = 1.89 [1.22-2.95); smoked with little tobacco, aOR = 1.39 [1.09-1.76]), frequency of cannabis use (aOR = 1.04 [1.01-1.06]), home cultivation (aOR = 1.56 [1.13-2.15]), at-ridsk alcohol use (aOR = 0.68 [0.54-0.84]), and previous-month opiate use (aOR = 1.67 [1.22-2.30]). A greater understanding of the distinct profiles of regular cannabis users could inform harm reduction strategies and care access for this population. Further studies are needed to better understand the boundaries between therapeutic and recreational use.

Changes in secondary substance use after the onset of the COVID-19 pandemic among people who use cannabis: Findings from a web-based sample of adults in the United States

The coronavirus disease 2019 (COVID-19) pandemic has had widespread impacts on mental health and substance use. Increases in cannabis use have been documented in the United States, but little is known about how other substance use has changed among people who use cannabis. We sought to examine changes in alcohol, tobacco, opioid, and stimulant use during COVID-19 and explore how these changes relate to patterns of cannabis use. Data were obtained from a web-based survey of adults in the United States who use cannabis (n = 1,471) administered in September 2020. Using data reported in retrospective (prepandemic) and time-of-survey assessment periods, we explored changes in the prevalence of regular (≥ weekly) alcohol, tobacco, opioid, and stimulant use during COVID-19 among respondents who used medical and nonmedical cannabis. We used modified Poisson regression to examine cannabis-related correlates of increasing or decreasing secondary substance use during the pandemic. There was a slight but significant increase in ≥weekly alcohol use in the medical use group only (41.4%-47.0%, p = .034). ≥ Weekly tobacco, opioid, and stimulant use did not change significantly. Pandemic-concurrent shifts in secondary substance use depended on interacting cannabis-related factors including medical cannabis use, prepandemic cannabis frequency, and pandemic-concurrent frequency changes. For example, ≥ weekly prepandemic cannabis use was significantly and positively associated with decreasing opioid use frequency among the medical cannabis use group only. Assessments of the pandemic's effects on substance use should consider relationships between cannabis and other substances, which may differ according to cannabis-specific behaviors, motives, and contexts of use. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

An Observational Cross-Sectional Survey Exploring the Indications for and Responses to Medical Marijuana Use in Certified Patients in Pennsylvania

INTRODUCTION/OBJECTIVES

Medical cannabis programs across the country vary and differ in their qualifying conditions for medical cannabis use. This has led to a gap in knowledge regarding the specific needs of cannabis patients, including the most common reason patients seek medical cannabis. The purpose of this study was to examine the current needs of medical cannabis patients in order to better inform future research, and to evaluate potential needs in policy changes in states with more restrictive qualifying conditions for medical cannabis use.

METHODS

A cross-sectional survey study was administered (n = 207) at a Laurel Harvest Labs dispensary in Pennsylvania. Participants were qualified medical cannabis users and were recruited as a convenience sample when entering the dispensary. The survey asked questions regarding participant demographics, medical cannabis qualifying conditions, usage, methods of administration, adverse effects, tolerance, and impact of medical cannabis on medication, alcohol, and tobacco use. Chi-squared or Fisher's exact tests were conducted for analyses involving categorical data.

RESULTS

The mean age of respondents was 36.7 years (SD = 12.8), and the majority were male (61.4%) and white (84.7%). Respondents self-reported that anxiety disorder was the most common qualifying medical condition and the most common comorbid condition (50.1%; 69.3%) for medical cannabis use. Additionally, approximately 95% of users reported having no adverse effects from using medical cannabis, and 90% of users preferred inhalation through vaporization as the preferred method of consumption. More than 50% of participants reported an improvement in their symptoms where only 20% of users reported being tolerant to their current dose. More than 70% of respondents reported that obtaining medical cannabis was "easy" and 54% of users reported that the cost of medical cannabis was not a barrier to access.

CONCLUSIONS

Anxiety disorder is a prevalent condition for which medical cannabis is used; however, many states do not recognize anxiety disorder as a qualifying condition for medical cannabis. Further research on medical cannabis use for anxiety disorders is needed to evaluate proper dosing and responses to treatment.

Cannabis Adaptation During and After Alcohol Ignition Interlock Device Installation: A Longitudinal Study

OBJECTIVE

A common intervention to prevent alcohol-impaired driving are alcohol ignition interlock devices (IIDs), which prevent drivers with a blood alcohol concentration greater than .025% from starting the car. These devices force drivers to adapt their drinking to accommodate the device. Prior studies indicated a transfer of risk as some drivers with an IID may increase cannabis use as they decrease alcohol use. This study examines whether this increase in cannabis use persists after IID removal when alcohol use reverts to pre-IID levels.

METHOD

The data are from the Managing Heavy Drinking (MHD) study of drivers in New York State. The MHD is a comprehensive three-wave study of drivers convicted of driving under the influence from 2015 to 2020. Participants (N = 189) completed all waves, and provided oral fluid/blood and hair samples to measure cannabis and alcohol use, respectively. Mixed between-within analysis of variance was conducted to assess cannabis use at IID installation (Time 1), removal (Time 2), and at 6-month follow-up (Time 3).

RESULTS

In aggregate, participants increased their cannabis use over the course of the study. Drivers who decreased their alcohol use while the IID was installed on their car significantly increased their cannabis use while the IID was in place and further increased cannabis use after the device's removal.

CONCLUSIONS

IIDs are efficacious in preventing alcohol-impaired driving. However, in some cases, they may have the unintended effect of increasing other substance use. The current study outlines the need for supplemental treatment interventions while on IID to prevent a transfer of risk to other substances, or polysubstance use after the device is removed.

A difference-in-difference approach to examining the impact of cannabis legalization on disparities in the use of cigarettes and cannabis in the United States, 2004-17

AIMS

To estimate the impact of recreational and medical cannabis laws (RCL, MCL) on the use of cannabis and cigarettes in the United States.

DESIGN

A difference-in-difference approach was applied to data from the 2004-17 National Survey on Drug Use and Health (NSDUH).

SETTING

United States.

PARTICIPANTS

Nationally representative cross-sectional survey of Americans aged 12 years and older (combined analytical sample for 2004-17, n = 783 663).

MEASUREMENTS

Data on past-month use of (1) cigarettes and (2) cannabis were used to classify respondents into four groups: cigarette and cannabis co-use, cigarette-only use, cannabis-only use or no cigarette or cannabis use. State of residence was measured by self-report. MCL/RCL status came from state government websites.

FINDINGS

Difference-in-difference analyses suggest that MCL was associated with an increase in cigarette-cannabis co-use overall [adjusted odds ratio (aOR) = 1.09; 95% confidence interval (CI) = 1.02-1.16], with the greatest increases among those aged 50 years and above (aOR = 1.60; CI = 1.39-1.84), married (aOR = 1.19; CI = 1.07-1.31), non-Hispanic (NH) black (aOR = 1.14; CI = 1.02-1.07) and with a college degree or above (aOR = 1.15; CI = 1.06-1.24). MCL was associated with increases in cigarette-only use among those aged 50 years and above (aOR = 1.07; CI = 1.01-1.14) and NH black (aOR = 1.16; CI = 1.06-1.27) and increases in cannabis-only use among those aged 50 years and above (aOR = 1.24; CI = 1.07-1.44) and widowed/divorced/separated (aOR = 1.18; CI = 1.01-1.37). RCL was associated with an increase in cannabis-only use overall (aOR = 1.21; 95% CI = 1.09-1.34), a decline in cigarette-only use overall (aOR = 0.89; 95% CI = 0.81-0.97) and increases in co-use among those who were married (aOR = 1.24; CI = 1.02-1.50) and aged 50 years and above (aOR = 1.37; CI = 1.03-1.84).

CONCLUSIONS

Recreational and medical cannabis legalization have had a varying impact on the use, and co-use, of cannabis and cigarettes in the United States.

Do alcohol and cannabis substitute or complement each other? Analysis from behavioral economics for formulating public policy on substance use in Colombia

After alcohol and tobacco, cannabis is the third most used substance among young Colombian adults, and many consume alcohol and cannabis concomitantly. However, academics have debated whether these substances substitute or complement each other among consumers. Understanding the relationship between the price and demand for psychoactive substances can clarify consumption patterns and help to develop strategies to reduce harmful consumption. This paper summarizes worldwide evidence of both complementary and substitution relationships and discusses the most probable relationship types in Colombia based on its substance use patterns and current regulations. Like other countries, Colombia is considering legalizing recreational cannabis use. However, there is a growing concern that legalization would increase the negative impacts of cannabis and increase alcohol use among the young adult population. The lack of Colombian empirical studies about the impacts of legal changes on the cannabis market makes it difficult to predict how such changes would affect demand and price elasticities.

Family-Based Predictors of Alcohol Use Disorder (AUD) Recurrence and New Non-Alcohol Substance Use Disorder Onset Following Initial AUD Recovery

OBJECTIVE

Knowledge of factors that predict alcohol use disorder (AUD) recurrence or the subsequent switching to a different substance use disorder (SUD) after initial AUD recovery is especially crucial for preventive efforts that seek to alter life courses dominated by problematic substance use. This study evaluated whether the proportions (or densities) of first-degree relatives with AUD and non-alcohol substance use disorder (NASUD) histories predicted AUD recurrence or a new NASUD onset in a family member (i.e., proband) following initial AUD episode recovery.

METHOD

This research is based on a prospective and multigenerational data set collected as part of the Oregon Adolescent Depression Project (OADP). The initial proband cohort was selected randomly from nine high schools in western Oregon. The sample for this research consisted of OADP probands with histories of AUD who recovered from their first AUD episode by age 30 (n = 244). Lifetime SUD histories were also assessed for first-degree adult relatives of probands (n = 790).

RESULTS

In unadjusted and partially adjusted analyses, family densities of AUD predicted AUD recurrence among probands, and family densities of NASUDs predicted the onset of a new NASUD following first-episode AUD recovery. In fully adjusted analyses, the effect for AUD family histories on proband AUD recurrence remained, whereas the effect for family NASUD histories on new NASUD emergence was not maintained.

CONCLUSIONS

Family SUD histories have predictive relevance for the course of AUD following initial recovery as well as some specificity for the type of SUD recurrence subsequently experienced.

Family-Based Predictors of Alcohol Use Disorder (AUD) Recurrence and New Non-Alcohol Substance Use Disorder Onset Following Initial AUD Recovery

OBJECTIVE

Knowledge of factors that predict alcohol use disorder (AUD) recurrence or the subsequent switching to a different substance use disorder (SUD) after initial AUD recovery is especially crucial for preventive efforts that seek to alter life courses dominated by problematic substance use. This study evaluated whether the proportions (or densities) of first-degree relatives with AUD and non-alcohol substance use disorder (NASUD) histories predicted AUD recurrence or a new NASUD onset in a family member (i.e., proband) following initial AUD episode recovery.

METHOD

This research is based on a prospective and multigenerational data set collected as part of the Oregon Adolescent Depression Project (OADP). The initial proband cohort was selected randomly from nine high schools in western Oregon. The sample for this research consisted of OADP probands with histories of AUD who recovered from their first AUD episode by age 30 (n = 244). Lifetime SUD histories were also assessed for first-degree adult relatives of probands (n = 790).

RESULTS

In unadjusted and partially adjusted analyses, family densities of AUD predicted AUD recurrence among probands, and family densities of NASUDs predicted the onset of a new NASUD following first-episode AUD recovery. In fully adjusted analyses, the effect for AUD family histories on proband AUD recurrence remained, whereas the effect for family NASUD histories on new NASUD emergence was not maintained.

CONCLUSIONS

Family SUD histories have predictive relevance for the course of AUD following initial recovery as well as some specificity for the type of SUD recurrence subsequently experienced.

Coping Motives Mediate the Association of Trauma History with Problematic Cannabis Use in Young Adult Medical Cannabis Patients and Non-Patient Cannabis Users

Background: Despite evidence of the contribution of childhood trauma to the development of problematic cannabis use, its mediating pathways are largely unknown. Given the link between cannabis motives with trauma and problematic cannabis use, motives of use may represent a construct through which trauma impacts problematic cannabis use. Methods: A sample of 339 medical cannabis patient and non-patient young adult users from the Los Angeles area were sampled at baseline and one year later. The current study examined the impact of childhood trauma on problematic use through a variety of cannabis use motives. Results: Controlling for age, socioeconomic status, perceived stress, and baseline problematic use, endorsing the use of cannabis to cope with distress at baseline uniquely mediated the associations between different childhood trauma types (e.g., physical abuse, neglect, sexual trauma) and problematic use one year later. Experience of any childhood trauma was positively associated with coping motives, whereas emotional and physical abuse were positively associated with pain motives, and sexual abuse was positively associated with sleep motives. Using cannabis for coping and increasing attention/focus were also positively associated with higher problematic use, whereas using cannabis for sleep was inversely associated with problematic use one year later. Conclusions: The motives of coping with distress and inattention may represent intermediate constructs through which trauma leads to later problematic cannabis use. Results highlight the need to clarify the pathways between health and non-health-oriented motives and cannabis use over time.

Patterns of Cannabis and Alcohol Co-Use: Substitution Versus Complementary Effects

PURPOSE

The purpose of this review is to discuss the literature regarding the concurrent use (co-use) of alcohol and cannabis and competing hypotheses as to whether cannabis acts as a substitute for (i.e., replacing the effects of alcohol, resulting in decreased use) or a complement to (i.e., used to enhance the effects of alcohol, resulting in increased use) alcohol. The impact of cannabis use on alcohol-related outcomes has received increased attention in the wake of ongoing legalization of cannabis for both medical and recreational purposes. Evidence for both hypotheses exists in the literature across a broad range of data collection methods and samples and is carefully reviewed here. In addition, various mechanisms by which cannabis may act as an alcohol substitute or complement are explored in depth with the goal of better understanding equivocal findings.

SEARCH METHODS

This review includes articles that were identified from a search for studies on alcohol and cannabis co-use, with a specific focus on studies exploring complementary versus substitution aspects of co-use. Search terms were included in Google Scholar, PsycINFO, MEDLINE, and Web of Science. Eligible studies were those that measured alcohol and cannabis co-use in human samples in laboratory, survey, or ecological momentary assessment studies, or that directly referenced substitution or complementary patterns of use.

SEARCH RESULTS

Search results returned 650 articles, with 95 meeting inclusion criteria.

DISCUSSION AND CONCLUSIONS

Results of this review reveal compelling evidence for both substitution and complementary effects, suggesting nuanced yet significant distinctions across different populations examined in these studies. Several mechanisms for the impact of cannabis use on alcohol-related outcomes are identified, including patterns and context of co-use, timing and order of use, cannabinoid formulation, pharmacokinetic interactions, and user characteristics (including diagnostic status), all of which may influence substitution versus complementary effects. This review will inform future research studies examining this topic in both clinical and community samples and aid in the development of treatment and prevention efforts targeting those populations most vulnerable to negative consequences of co-use. Finally, this review highlights the need for additional research in more diverse samples and the use of mixed-methods designs to examine both pharmacological and contextual influences on co-use.

More harm than good? Cannabis, harm and the misuse of drugs act

Purpose

This paper aims to consider the nature of cannabis-related harms under the UK’s Misuse of Drugs Act (MDA). Written for the specific context of this four-paper special section on 50 years of the MDA, it argues that the MDA may cause more harm than it prevents.

Design/methodology/approach

An opinion piece offering a structured overview of cannabis-related harms under prohibition. It summarises existing evidence of the ways in which prohibition may exacerbate existing – and create new – harms related to the production, distribution, use and control of cannabis.

Findings

The paper argues that prohibition of cannabis under the MDA may cause more harm than it prevents.

Originality/value

It has long been argued that the MDA does not accurately or fairly reflect the harms of the substances it prohibits, and much existing research points to different ways in which drug prohibition can itself be harmful. The originality of this paper lies in bringing together these arguments and developing a framework for analysing the contribution of prohibition to drug-related harm.

Pharmacokinetics and Perceptions of Children and Young Adults Using Cannabis for Attention-Deficit/Hyperactivity Disorder and Oppositional Defiant Disorder: Protocol for a Mixed Methods Proof-of-Concept Study

Background

Despite the lack of evidence on the use of cannabis for the treatment of attention-deficit/hyperactivity disorder (ADHD), the growing perception that cannabis is safe has led more patients and caregivers to self-medicate. Some psychiatrists now authorize medicinal cannabis for patients with ADHD with features of oppositional defiant disorder (ODD) to curtail the unregulated (ie, self-medicated) use of recreational cannabis or to offer a therapeutic option to those who continue to experience symptoms after exhausting all other treatment options.

Objective

This protocol aims to explore the perceived effectiveness and pharmacokinetics of cannabis in youth and young adults, who are currently taking it as part of their treatment plan for ADHD with features of ODD, under the supervision of a psychiatrist.

Methods

Patients between the ages of 12 and 25 years with a diagnosis of ADHD and features of ODD, who are currently taking cannabis herbal extract (at a Δ⁹-tetrahydrocannabinol [THC]:cannabidiol [CBD] ratio of 1:20) as a treatment adjunct to stimulant pharmacotherapy will be recruited. A sample size of 10-20 individuals is estimated. The study interview will consist of (1) validated symptom rating scales (Swanson, Nolan, and Pelham-IV Questionnaire [SNAP-IV], 90-item; Patient Health Questionnaire, 9-item [PHQ-9]; and Screen for Child Anxiety Related Emotional Disorders [SCARED] tool to measure symptoms of ADHD and ODD, depression, and anxiety, respectively); (2) a semistructured interview to probe the experiences of using cannabis; and (3) a cannabis side effects survey. A cannabis product sample as well as 2 blood samples (a trough level and 2-hour postdose level) will be collected to measure plasma concentrations of cannabinoids and relevant metabolites (THC, CBD, 11-hydroxy-THC, 7-hydroxy-CBD, cannabichromene, and 11-nor-9-carboxy-THB) using liquid chromatography–tandem mass spectrometry (LC–MS/MS). Self-report rating scales (SNAP-IV, SCARED, and PHQ-9) will be scored in accordance with standard protocols and compared to retrospective scores obtained from the participant’s chart. Demographic variables (age, weight, and race), symptom scores, and blood levels (peaks and troughs) of THC, CBD, cannabichromene (CBC), and metabolites will be summarized using descriptive statistics. Relationships between plasma concentrations and symptom scores will be determined using analysis of variance, and multiple regression analysis will be performed to determine associations between plasma concentrations and demographic variables (age, weight, and ethnicity). The qualitative data will be audio-recorded and transcribed and organized into themes.

Results

The protocol was approved by the Biomedical Research Ethics Board at the University of Saskatchewan (protocol #1726), and recruitment began in May 2021.

Conclusions

This proof-of-concept study will explore the potential treatment effectiveness of medical cannabis in participants with ADHD and ODD through a mixed methods approach to inform future research in this area.

International Registered Report Identifier (IRRID)

DERR1-10.2196/31281

Co-exposure of cocaine and cannabinoids and its association with select biological, behavioural and health outcomes: A systematic scoping review of multi-disciplinary studies

Cocaine use entails severe health- and social-related harms globally. Treatment options for cocaine dependence are highly limited. Benefits of cannabinoids for addiction have been documented, making it opportune to examine existing data on the possible outcomes associated with cannabinoids and cocaine co-use. We conducted a systematic scoping review following the PRISMA guidelines of peer-reviewed, English-language studies published from 2000 to 2021 in four databases (Medline, Web-of-Science, CINAHL Plus, and PsycInfo), assessing the co-exposure of cannabis/cannabinoids with cocaine on behavioural, biological or health outcomes. Both quantitative and qualitative, as well as humans and pre-clinical animals' studies (n=46) were included. Pre-clinical studies (n=19) showed mostly protective effects of cannabidiol (CBD) administration on animal models of addiction (e.g., cocaine-craving, -relapse, and -withdrawal) and cocaine-toxicity. Tetrahydrocannabinol (THC) had more inconsistent results, with both protective and counter-protective effects. Human studies (n=27) were more heterogeneous and assessed natural ongoing cannabis and cocaine use or dependence. Quantitative-based studies showed mostly enhanced harms in several outcomes (e.g., cocaine use, mental health); two available clinical trials found no effect upon CBD administration on cocaine-related treatment outcomes. Qualitative data-based studies reported cannabis use as a substitute for or to alleviate harms of crack-cocaine use. While pre-clinical studies suggest a potential of cannabinoids, especially CBD, to treat cocaine addiction, the few trials conducted in humans found no benefits. Cannabis co-use by cocaine users commonly presents a risk factor, entailing enhanced harms for users. More rigorous, controlled trials are still necessary to investigate cannabinoids' potential considering pre-clinical findings and reported benefits from specific drug users.

A systematic review of addiction substitution in recovery: Clinical lore or empirically-based?

This systematic review synthesized the literature examining addiction substitution during recovery from substance use or behavioral addictions. A total of 96 studies were included with sample sizes ranging from 6 to 14,885. The most common recovery addictions were opioids (30.21%), followed by cannabis (20.83%), unspecified use (17.71%), nicotine (12.50%), alcohol (12.50%), cocaine (4.17%), and gambling (2.08%). Statistical results were provided by 70.83% of the studies. Of these, 17.65% found support for addiction substitution, whereas 52.94% found support for concurrent recovery. A total of 19.12% found no statistical changes and 10.29% found both significant increases and decreases. The remaining 29.17% of studies provided descriptive data, without statistical tests. Predictors of addiction substitution were provided by 22.92% of the studies and 11.46% included information on impact of addiction substitution on treatment outcomes. Overall, male gender, younger age, greater substance use severity, and presence of mental health disorders were associated with addiction substitution. Addiction substitution was associated with poorer treatment outcomes. A limitation of the present systematic review is the use of significance counting for the quantitative synthesis. More research examining changes in addiction during recovery would aid in the development of more effective treatments for addictive disorders and prevent addiction substitution.

Cannabis against chronic musculoskeletal pain: a scoping review on users and their perceptions

Background

Chronic musculoskeletal pain (CMP) may lead to reduced physical function and is the most common cause of chronic non-cancer pain. Currently, the pharmacotherapeutic options against CMP are limited and frequently consist of pain management with non-steroidal anti-inflammatories, gabapentinoids, or opioids, which carry major adverse effects. Although the effectiveness of medical cannabis (MC) for CMP still lacks solid evidence, several patients suffering from it are exploring this therapeutic option with their physicians.

Objectives

Little is known about patients’ perceptions of their MC treatment for CMP. We aimed to increase this knowledge, useful for healthcare professionals and patients considering this treatment, by conducting a scoping literature review, following guidance by Arksey and O’Malley, to describe the views and perceptions of adult patients who had consumed MC to relieve chronic CMP.

Methods

Databases (PUBMED, EMBASE, Web of Science) and websites were searched using combinations of controlled and free vocabulary. All studies and study designs reporting on patients’ perceptions regarding MC against CMP were considered. Studies had to include adult patients reporting qualitatively or quantitatively, i.e., through questionnaires, on MC use to treat CMP or other non-cancer pain, since studies reporting exclusively on perceptions regarding CMP were very rare. Study characteristics were extracted and limitations of the study quality were assessed. The review includes patients’ demographic characteristics, patterns of MC use, perceived positive and negative effects, use of alcohol or other drugs, reported barriers to CM use, and funding sources of the studies.

Results

Participants of the 49 included studies reported that MC use helped them to reduce CMP and other chronic non-cancer pain, with only minor adverse effects, and some reported improved psychological well-being.

In the included studies, men represent between 18 and 88% of the subjects. The mean age of participants in these studies (42/49) varied between 28.4 and 62.8 years old. The most common route of administration is inhalation.

Conclusion

MC users suffering from CMP or other chronic non-cancer pain perceived more benefits than harms. However, the information from these studies has several methodological limitations and results are exploratory. These user-reported experiences must thus be examined by well-designed and methodologically sound clinical or observational studies, particularly regarding CMP, where reports are very scarce.

Supplementary Information

The online version contains supplementary material available at 10.1186/s42238-021-00096-8.

Effects of cannabis use on alcohol consumption in a sample of treatment-engaged heavy drinkers in Colorado

BACKGROUND AND AIMS

Cannabis is commonly used among people who drink alcohol, but evidence suggests a nuanced relationship between alcohol consumption and cannabis use. In particular, among individuals undergoing alcohol treatment the impact of cannabis on alcohol intake may depend upon cannabis use frequency. We aimed to test the effects of within-day cannabis use on total drinks consumed and likelihood of binge drinking on a given day among all participants and compare these relationships between males and females and between individuals who reported infrequent and frequent cannabis use.

DESIGN

This observational study is a substudy of a larger randomized controlled trial (RCT). Individuals were included from the RCT if they reported any cannabis use and were divided into groups based on cannabis use patterns. Alcohol use was compared within and between groups.

SETTING

Individuals were recruited from 2016 to 2020 from community and university settings in Denver and Boulder, CO, USA.

PARTICIPANTS

Of the 182 individuals enrolled in the RCT, 96 cannabis-using subjects were included in these analyses.

MEASUREMENTS

Subjects completed a time-line follow-back (TLFB) at baseline, 4, 8 (end of treatment) and 20 weeks. Daily data on alcohol and cannabis use from the TLFB at all time-points were analyzed.

FINDINGS

Across the sample (n = 96), individuals drank approximately 29% fewer drinks [95% confidence interval (CI) = 18-39%, P < 0.001] and were 2.06 times (95% CI =1.37-3.08, P < 0.001) less likely to have a binge-drinking episode on days that cannabis was used compared with days that cannabis was not used. These patterns were observed in males, females and the infrequent and frequent cannabis use groups. Findings were inconclusive regarding differences in the association between cannabis use and alcohol outcomes when comparing males and females and when comparing infrequent and frequent cannabis use groups.

CONCLUSIONS

Heavy drinkers engaged in treatment to reduce their alcohol consumption who also use cannabis appear to increase their cannabis use on days when they reduce their alcohol consumption.

Green Hope: Perspectives on Cannabis from People who Use Opioids

While states are implementing policies to legalize cannabis for medical or recreational purposes, it remains a Schedule 1 controlled substance with no medical uses according to US federal law. The perception of cannabis depends on social and cultural norms that impact political institutions involved in implementing policy. Because of negative social constructions, such as the "gateway hypothesis," legalization of cannabis has been slow and contentious. Recent studies suggest that cannabis can help combat the opioid epidemic. This paper fills a gap in our understanding of how cannabis is viewed by people who are actively misusing opioids and not in treatment. Using ethnographic methods to recruit participants living in a state that legalized cannabis and a state where cannabis was illegal, survey and interview data were analyzed informed by a social constructionist lens. Findings from their "insider perspective" suggest that for some people struggling with problematic opioid use, cannabis can be beneficial.

Phytocannabinoids - An Overview of the Analytical Methodologies for Detection and Quantification of Therapeutically and Recreationally Relevant Cannabis Compounds

The legalization of the cultivation of low Δ9-tetrahydrocannabinol (Δ9-THC) and high cannabidiol (CBD) Cannabis Sativa plants is gaining momentum around the world due to increasing demand for CBD-containing products. In many countries where CBD oils, extracts and CBD-infused foods and beverages are being sold in health shops and supermarkets, appropriate testing of these products is a legal requirement. Normally this involves determining the total Δ9-THC and CBD and their precursor tetrahydrocannabinolic acids (THCA) and cannabidiolic acid (CBDA). As our knowledge of the other relevant cannabinoids expands, it is likely so too will the demand for them as additives in many consumer products ensuring a necessity for quantification methods and protocols for their identification. This paper discusses therapeutically relevant cannabinoids found in Cannabis plant, the applicability and efficiency of existing extraction and analytical techniques as well as the legal requirements for these analyses.

Memantine Prevents the WIN 55,212-2 Evoked Cross-Priming of Ethanol-Induced Conditioned Place Preference (CPP)

The activation of the endocannabinoid system controls the release of many neurotransmitters involved in the brain reward pathways, including glutamate. Both endocannabinoid and glutamate systems are crucial for alcohol relapse. In the present study, we hypothesize that N-methyl-D-aspartate (NMDA) glutamate receptors regulate the ability of a priming dose of WIN 55,212-2 to cross-reinstate ethanol-induced conditioned place preference (CPP). To test this hypothesis, ethanol-induced (1.0 g/kg, 10% w/v, i.p.) CPP (unbiased method) was established using male adult Wistar rats. After CPP extinction, one group of animals received WIN 55,212-2 (1.0 and 2.0 mg/kg, i.p.), the cannabinoid receptor 1 (CB1) agonist, or ethanol, and the other group received memantine (3.0 or 10 mg/kg, i.p.), the NMDA antagonist and WIN 55,212-2 on the reinstatement day. Our results showed that a priming injection of WIN 55,212-2 (2.0 mg/kg, i.p.) reinstated (cross-reinstated) ethanol-induced CPP with similar efficacy to ethanol. Memantine (3.0 or 10 mg/kg, i.p.) pretreatment blocked this WIN 55,212-2 effect. Furthermore, our experiments indicated that ethanol withdrawal (7 days withdrawal after 10 days ethanol administration) down-regulated the CNR1 (encoding CB1), GRIN1/2A (encoding GluN1 and GluN2A subunit of the NMDA receptor) genes expression in the prefrontal cortex and dorsal striatum, but up-regulated these in the hippocampus, confirming the involvement of these receptors in ethanol rewarding effects. Thus, our results show that the endocannabinoid system is involved in the motivational properties of ethanol, and glutamate may control cannabinoid induced relapse into ethanol seeking behavior.

Dual trajectories of cannabis and alcohol use among young adults in a state with legal nonmedical cannabis

BACKGROUND

Understanding the nature of the association between cannabis and alcohol use within individuals over time in the era of legalized cannabis is of crucial importance for assessing the public health consequences of increasing cannabis use. An important unanswered question is whether cannabis and alcohol use substitute for one another. Specifically, is greater use of one substance associated with less use of the other substance (i.e., a negative association) or are the substances complementary and their association positive?

METHODS

We used 24 consecutive months of data on a young adult sample (n = 774; 56% female, age 18-25 during the study) who drank alcohol in the year prior to enrollment. The sample was recruited in Washington State in 2015/2016 (after legalization of nonmedical cannabis) using media advertisements and community flyers and outreach. Using parallel process latent growth curve models, we assessed three types of association between cannabis and alcohol use across the 24-month period: (1) an association between average levels of cannabis and alcohol use; (2) an association between rates of change in cannabis and alcohol use; and (3) correlations between shorter-term deviations/fluctuations off of longer-term trajectories of level and change in cannabis and alcohol use.

RESULTS

We found a positive association between the average frequency of cannabis and alcohol use; individuals who used cannabis more frequently on average also drank alcohol more frequently on average. Change over time in cannabis use was positively associated with change in alcohol use. There was also a contemporaneous positive association between fluctuations in cannabis and alcohol use.

CONCLUSIONS

Overall, we found no evidence of substitution. Rather, the results suggest a complementary relationship between cannabis and alcohol use, such that the use of cannabis and alcohol rises and falls together.

"If I knew I could get that every hour instead of alcohol, I would take the cannabis": need and feasibility of cannabis substitution implementation in Canadian managed alcohol programs

Background

While there is robust evidence for strategies to reduce harms of illicit drug use, less attention has been paid to alcohol harm reduction for people experiencing severe alcohol use disorder (AUD), homelessness, and street-based illicit drinking. Managed Alcohol Programs (MAPs) provide safer and regulated sources of alcohol and other supports within a harm reduction framework. To reduce the impacts of heavy long-term alcohol use among MAP participants, cannabis substitution has been identified as a potential therapeutic tool.

Methods

To determine the feasibility of cannabis substitution, we conducted a pre-implementation mixed-methods study utilizing structured surveys and open-ended interviews. Data were collected from MAP organizational leaders (n = 7), program participants (n = 19), staff and managers (n = 17) across 6 MAPs in Canada. We used the Consolidated Framework for Implementation Research (CFIR) to inform and organize our analysis.

Results

Five themes describing feasibility of CSP implementation in MAPs were identified. The first theme describes the characteristics of potential CSP participants. Among MAP participants, 63% (n = 12) were already substituting cannabis for alcohol, most often on a weekly basis (n = 8, 42.1%), for alcohol cravings (n = 15, 78.9%,) and withdrawal (n = 10, 52.6%). Most MAP participants expressed willingness to participate in a CSP (n = 16, 84.2%). The second theme describes the characteristics of a feasible and preferred CSP model according to participants and staff. Participants preferred staff administration of dry, smoked cannabis, followed by edibles and capsules with replacement of some doses of alcohol through a partial substitution model. Themes three and four highlight organizational and contextual factors related to feasibility of implementing CSPs. MAP participants requested peer, social, and counselling supports. Staff requested education resources and enhanced clinical staffing. Critically, program staff and leaders identified that sustainable funding and inexpensive, legal, and reliable sourcing of cannabis are needed to support CSP implementation.

Conclusion

Cannabis substitution was considered feasible by all three groups and in some MAPs residents are already using cannabis. Partial substitution of cannabis for doses of alcohol was preferred. All three groups identified a need for additional supports for implementation including peer support, staff education, and counselling. Sourcing and funding cannabis were identified as primary challenges to successful CSP implementation in MAPs.

Association between marijuana use and nonmedical prescription opioid use in the United States: are we shifting from one epidemic to another?

The United States (US) is grappling with a severe opioid epidemic. Marijuana is emerging as a therapy for pain management and an alternative to opioids, but little evidence supports its long-term benefits. This study aims to examine the association of marijuana use among patients on prescription pain relievers in a retrospective cross-sectional study using zero-inflated negative binomial regression. The recipients of prescription pain medicines were identified using National Survey on Drug Use and Health (2015-2017). Irrespective of the state marijuana laws, marijuana use days were 34% higher and odds of having zero days of marijuana use were 73% lower in those using nonmedical prescription opioids vs. not (IRR = 1.34, p < 0.0001; OR = 0.27, p < 0.0001, respectively). In the absence of consequential evidence supporting marijuana for pain management and more states venturing into legalizing it, there needs to be more caution as the country struggles to recover from one epidemic.

The association between cannabis use and outcome in pharmacological treatment for opioid use disorder

BACKGROUND

With the ongoing opioid crisis and policy changes regarding legalization of cannabis occurring around the world, it is necessary to consider cannabis use in the context of opioid use disorder (OUD) and its treatment. We aimed to examine (1) past-month cannabis use in patients with OUD, (2) self-reported cannabis-related side effects and craving, and (3) the association between specific characteristics of cannabis use and opioid use during treatment in cannabis users.

METHODS

Participants receiving pharmacological treatment for OUD (n = 2315) were recruited from community-based addiction treatment clinics in Ontario, Canada, and provided information on past-month cannabis use (self-report). Participants were followed for 3 months with routine urine drug screens in order to assess opioid use during treatment. We used logistic regression analysis to explore (1) the association between any cannabis use and opioid use during treatment, and (2) amongst cannabis-users, specific cannabis use characteristics associated with opioid use. Qualitative methods were used to examine responses to the question: "What effect does marijuana have on your treatment?".

RESULTS

Past-month cannabis use was reported by 51% of participants (n = 1178). Any cannabis use compared to non-use was not associated with opioid use (OR = 1.03, 95% CI 0.87-1.23, p = 0.703). Amongst cannabis users, nearly 70% reported daily use, and half reported experiencing cannabis-related side effects, with the most common side effects being slower thought process (26.2%) and lack of motivation (17.3%). For cannabis users, daily cannabis use was associated with lower odds of opioid use, when compared  with occasional use (OR = 0.61, 95% CI 0.47-0.79, p < 0.001) as was older age of onset of cannabis use (OR = 0.97, 95% CI 0.94, 0.99, p = 0.032), and reporting cannabis-related side effects (OR = 0.67, 95% CI 0.51, 0.85, p = 0.001). Altogether, 75% of cannabis users perceived no impact of cannabis on their OUD treatment.

CONCLUSION

Past-month cannabis use was not associated with more or less opioid use during treatment. For patients who use cannabis, we identified specific characteristics of cannabis use associated with differential outcomes. Further examination of characteristics and patterns of cannabis use is warranted and may inform more tailored assessments and treatment recommendations.

State Medical Cannabis Laws Associated With Reduction in Opioid Prescriptions by Orthopaedic Surgeons in Medicare Part D Cohort

INTRODUCTION

Opioid prescriptions and abuse remain a significant national concern. Cannabinoids offer a potentially attractive nonopioid analgesic option for orthopaedic patients, and 32 US states have passed medical cannabis laws (MCLs), legalizing patient access to cannabinoids. We examine the association between implementation of state cannabis laws and prescribing patterns for opioids by orthopaedic surgeons in Medicare Part D patients between 2013 and 2017.

METHODS

Using the Medicare Part D Prescription Drug Event database, we measured annual aggregate daily doses of all opioid medications (excluding buprenorphine) prescribed by orthopaedic surgeons in each US state (and DC), in addition to total daily doses of opioid medications by generic name (hydrocodone, oxycodone, fentanyl, morphine, methadone, and "other opioids"). We used adjusted linear regression models to examine associations between state-specific cannabis regulations (state MCL, MCL type-dispensary or home cultivation, and recreational cannabis legalization) and annual total daily doses of opioid medications (all opioids and opioid types, separately).

RESULTS

State MCLs were associated with a statistically significant reduction in aggregate opioid prescribing of 144,000 daily doses (19.7% reduction) annually (95% confidence interval [CI], -0.535 to -0.024 million; P < 0.01). States with MCLs allowing access to in-state dispensaries had a statistically significant reduction in total opioid prescriptions of 96,000 daily doses (13.1%) annually (95% CI, -0.165 to -0.026 million; P < 0.01). Specifically, MCLs were associated with a statistically significant reduction of 72,000 daily doses of hydrocodone annually (95% CI, -0.164 to -0.019 million; P < 0.01). No significant association between recreational marijuana legalization and opioid prescribing was found.

CONCLUSION

Orthopaedic surgeons are among the highest prescribers of opioids, highlighting the importance of providing nonopioid analgesic alternatives in efforts to reduce opioid use in the patient cohort. This study is the first to examine the association between implementation of state cannabis laws and prescribing patterns for opioids by orthopaedic surgeons in Medicare Part D patients.

LEVEL OF EVIDENCE

Population-based ecological study.

Disagreement and Uncertainty Among Experts About how to Respond to Marijuana Use in Patients on Long-term Opioids for Chronic Pain: Results of a Delphi Study

BACKGROUND

Marijuana use is common among patients on long-term opioid therapy (LTOT) for chronic pain, but there is a lack of evidence to guide clinicians' response.

OBJECTIVE

To generate expert consensus about responding to marijuana use among patients on LTOT.

DESIGN

Analysis from an online Delphi study.

SETTING/SUBJECTS

Clinician experts in pain and opioid management across the United States.

METHODS

Participants generated management strategies in response to marijuana use without distinction between medical and nonmedical use, then rated the importance of each management strategy from 1 (not at all important) to 9 (extremely important). A priori rules for consensus were established, and disagreement was explored using cases. Thematic analysis of free-text responses examined factors that influenced participants' decision-making.

RESULTS

Of 42 participants, 64% were internal medicine physicians. There was consensus that it is not important to taper opioids as an initial response to marijuana use. There was disagreement about the importance of tapering opioids if there is a pattern of repeated marijuana use without clinical suspicion for a cannabis use disorder (CUD) and consensus that tapering is of uncertain importance if there is suspicion for CUD. Three themes influenced experts' perceptions of the importance of tapering: 1) benefits and harms of marijuana for the individual patient, 2) a spectrum of belief about the overall riskiness of marijuana use, and 3) variable state laws or practice policies.

CONCLUSIONS

Experts disagree and are uncertain about the importance of opioid tapering for patients with marijuana use. Experts were influenced by patient factors, provider beliefs, and marijuana policy, highlighting the need for further research.

Why Switch? - Motivations for Self-Substitution of Illegal Drugs

Self-substitution is the conscious switch from one drug to another for reasons such as price, availability, desired effect, or perceived benefit of the substitute drug. Purpose/Objectives: This study aimed to describe drug use patterns and motivations associated with substitution. We examined correlates of lifetime substitution among individuals with substance use disorder. Methods: A cross-sectional study of 771 treatment-enrolled individuals. We used self-report for determining the lifetime prevalence, correlates, and motivations for substitution. Results: Of the 771 respondents, 570 (73.9%) reported ever substituting their preferred substance. The main incentives for substitution were availability (23.7%) and curiosity (20.2%). Among heroin or cannabis preferers, improved effects or less adverse effects of the substitute drug, self-medication, and managing withdrawal symptoms were significant substitution incentives. Increased odds for substitution were observed for past 12 months use of cannabis (OR = 1.51, CI = 1.06-4.52), prescription opioids (OR = 2.86, CI = 1.81-4.52), novel psychoactive substances (OR = 2.68, CI = 1.64-4.36), and repeated admission (OR = 1.50, CI = 1.05-2.14). Older age at onset-of-use was negatively associated with substitution (OR = 0.95, CI = 0.93-0.98). Conclusions: Self-substitution of one substance for another is a highly prevalent behavior among treatment-enrolled patients with substance use disorder. Clinicians caring for substance use disorder patients should be aware of substitution patterns involving the use of highly potent substances, which constitutes a risk to patients. Results underscore the benefit of substitution patterns analyses, as they reveal important information on the characteristics of persons who use drugs and their motivations.

Impact of state-level cannabis legalization on poly use of alcohol and cannabis in the United States, 2004-2017

BACKGROUND

Cannabis policy has shifted toward legalization in many parts of the United States (US). While attention has been focused on whether legalization will lead to changes in cannabis use, it is conceivable that legalization will also affect use of substances that individuals frequently use with cannabis. This study assessed whether cannabis legalization impacted the prevalence of poly use of cannabis and alcohol from 2004 to 2017 and estimated the prevalence of cannabis and alcohol poly use in 2017.

METHODS

Public and restricted-use data from the US 2004-2017 National Survey on Drug Use and Health were analyzed. Data on past-month cannabis and alcohol use were assessed each year. Cannabis legalization was determined by the presence or absence of medical marijuana laws (MML) and recreational marijuana laws (RML) in each state. Difference-in-difference approach was used to estimate the association of MML and RML on cannabis and alcohol use overall and by sociodemographic subgroups (e.g., age, income, education).

RESULTS

Between 2004 and 2017, poly use of cannabis and alcohol increased while alcohol-only use decreased. MML were associated with increases in poly use only among adults over age 50 and among those with higher annual incomes and higher education, while RML were associated with increases in poly use broadly among adults across sociodemographic groups.

CONCLUSIONS

Legalization of cannabis was associated with increases in cannabis-alcohol poly use in the US. RML were associated with increases across demographics, while the impact of MML was more limited to certain sociodemographic groups.

Prevalence and Correlates of Medicinal Cannabis Use Among Adolescents

PURPOSE

Prior studies of medicinal cannabis use (MCU) have focused primarily on adults. This study examined the prevalence and correlates of self-reported MCU among adolescents.

METHODS

Secondary school students (grades 9-12; N = 3,221) completed a cross-sectional survey in classrooms across Ontario, Canada, in 2016-2017. Participants reported on cannabis use behavior, cannabis dependence, other drugs use, and general health and sleep. Participants reporting cannabis use in the past year were grouped based on whether they reported MCU or not (i.e., recreational cannabis use only [RCU-only]).

RESULTS

An estimated 6.89% (95% confidence interval 5.48%-8.63%) of students reported MCU, representing one quarter of the students reporting current cannabis use. Relative to the RCU-only group, the MCU group reported using cannabis more frequently, were more likely to report vaping and eating cannabis, had greater risk for cannabis dependence, perceived cannabis as less harmful, were more likely to report tobacco use, recreational use of other drugs, and medicinal use of sedatives or tranquilizers, and were less likely to report good health and sleeping for seven or more hours per night. Frequency of cannabis use accounted for differences between MCU and RCU-only groups in cannabis dependence risk, recreational use of other drugs, and perceiving cannabis as harmful, but it did not account for the other differences.

CONCLUSIONS

A sizable portion of secondary school students report MCU, which appears to be associated with more frequent cannabis use and certain substance use and health-related correlates. Research is needed to further characterize motives for self-reported MCU among adolescents.

Medical Marijuana and Opioids (MEMO) Study: protocol of a longitudinal cohort study to examine if medical cannabis reduces opioid use among adults with chronic pain

INTRODUCTION

In the USA, opioid analgesic use and overdoses have increased dramatically. One rapidly expanding strategy to manage chronic pain in the context of this epidemic is medical cannabis. Cannabis has analgesic effects, but it also has potential adverse effects. Further, its impact on opioid analgesic use is not well studied. Managing pain in people living with HIV is particularly challenging, given the high prevalence of opioid analgesic and cannabis use. This study's overarching goal is to understand how medical cannabis use affects opioid analgesic use, with attention to Δ9-tetrahydrocannabinol and cannabidiol content, HIV outcomes and adverse events.

METHODS AND ANALYSES

We are conducting a cohort study of 250 adults with and without HIV infection with (a) severe or chronic pain, (b) current opioid use and (c) who are newly certified for medical cannabis in New York. Over 18 months, we collect data via in-person visits every 3 months and web-based questionnaires every 2 weeks. Data sources include: questionnaires; medical, pharmacy and Prescription Monitoring Program records; urine and blood samples; and physical function tests. Using marginal structural models and comparisons within participants' 2-week time periods (unit of analysis), we will examine how medical cannabis use (primary exposure) affects (1) opioid analgesic use (primary outcome), (2) HIV outcomes (HIV viral load, CD4 count, antiretroviral adherence, HIV risk behaviours) and (3) adverse events (cannabis use disorder, illicit drug use, diversion, overdose/deaths, accidents/injuries, acute care utilisation).

ETHICS AND DISSEMINATION

This study is approved by the Montefiore Medical Center/Albert Einstein College of Medicine institutional review board. Findings will be disseminated through conferences, peer-reviewed publications and meetings with medical cannabis stakeholders.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT03268551); Pre-results.

Illicit Cannabis Usage as a Management Strategy in New Zealand Women with Endometriosis: An Online Survey

Background: Endometriosis affects around 10% of women worldwide. Many women with endometriosis struggle with finding adequate pain management, and data from other countries suggest that women use cannabis, either legal or illicit, to help manage their endometriosis symptoms. The aim of this study was to determine use of cannabis where endometriosis was self-identified as a condition that was being treated with cannabis, as well as the impact of cannabis use on the usage on other pharmaceuticals. Materials and Methods: A cross-sectional online survey of those using cannabis for health-related conditions run between May and July 2019. This article reports on the subset of this larger data set for those reporting they had a diagnosis of endometriosis and/or polycystic ovary syndrome. Data were collected on demographics, modes of cannabis administration, symptoms treated, changes in pharmaceutical usage, and adverse events. Results: Two hundred thirteen valid responses were analyzed. Mean age of respondents was 32 years and 79.8% were current cannabis users. The most common outcomes that cannabis was used for were to improve pain relief (95.5%) and to improve sleep (95.5%). Respondents reported that their symptom was "much better" for pain (81%), sleep (79%), and nausea or vomiting (61%). Over three-quarters (81.4%) indicated cannabis had reduced their normal medication usage. Over half (59%) were able to completely stop a medication, most commonly (66%) analgesics. Opioids (40%) were the most common class of analgesic stopped. Conclusions: Cannabis is reported as an effective intervention for pain and other endometriosis symptoms with potential substitution effects on opioid usage.

The positive and negative cardiovascular effects of cannabis

INTRODUCTION

The use of cannabis and its derivatives have increased steadily over the past few decades, prompting patients and clinicians to increasingly inquire about its health effects and safety profile. However, despite promising evidence suggesting therapeutic utilization, cannabis remains a controlled substance in most countries and is largely considered to have no medical or recreational benefit; thus, a lack of observational studies and randomized control trials exist to outline positive and negative health implications. Ultimately, this leaves patients, health-care professionals, and policymakers without necessary evidence required to make informed decisions on cannabis use.

AREAS COVERED

This review outlines cannabis in a clinical setting and delves into specific effects of cannabinoids on cardiovascular health and disease. It discusses positive and negative health implications associated with cannabis, mechanisms in cardiovascular disease, and reveals methods guiding cannabis use in the clinical setting.

EXPERT OPINION

Advances in research are necessary to guide decisions regarding cannabinoid use. Countries that have federally legalized cannabis have a unique opportunity to study cardiovascular implications in an unbiased and comprehensive manner. Ultimately, as cannabis use will inevitably increase, researchers, clinicians, and policymakers must work together to ensure cannabis is utilized in a way that is therapeutically beneficial.

Reductions in alcohol use following medical cannabis initiation: results from a large cross-sectional survey of medical cannabis patients in Canada

BACKGROUND

Evidence details how cannabis can influence the use of other psychoactive substances, including prescription medications, alcohol, tobacco and illicit drugs, but very little research has examined the factors associated with these changes in substance use patterns. This paper explores the self-reported use of cannabis as a substitute for alcohol among a Canadian medical cannabis patient population.

METHODS

Data was derived from a survey of 2102 people enrolled in the Canadian medical cannabis program. We included 973 (44%) respondents who reported using alcohol on at least 10 occasions over a 12 month period prior to initiating medical cannabis, and then used retrospective data on the frequency and amount of alcohol use pre-and post medical cannabis initiation to determine which participant characteristics and other variables were associated with reductions and/or cessation of alcohol use.

RESULTS

Overall, 419 (44%) participants reported decreases in alcohol usage frequency over 30 days, 323 (34%) decreased the number of standard drinks they had per week, and 76 (8%) reported no alcohol use at all in the 30 days prior to the survey. Being below 55 years of age and reporting higher rates of alcohol use in the pre-period were both associated with greater odds of reducing alcohol use, and an intention to use medical cannabis to reduce alcohol consumption was associated with significantly greater odds of both reducing and ceasing alcohol use altogether.

CONCLUSIONS

Our findings suggest that medical cannabis initiation may be associated with self-reported reductions and cessation of alcohol use among medical cannabis patients. Since alcohol is the most prevalent recreational substance in North America, and its use results in significant rates of criminality, morbidity and mortality, these findings may result in improved health outcomes for medical cannabis patients, as well as overall improvements in public health and safety.

A content analysis of internet information sources on medical cannabis

BACKGROUND

Medical cannabis users report that their knowledge regarding cannabis is predominantly from their own personal experiences and the Internet.

OBJECTIVE

We summarize and describe information found through Internet searches on medical cannabis in English language websites.

METHODS

We used terms related to medical cannabis in the Google search engine between November and December 2019. Resulting websites were catalogued and coded for content, including mentions of health and medical conditions, pharmacology, dosage, harmful or adverse effects, harm reduction techniques, cautions or warnings, products for sale, and credentials.

RESULTS

We coded 344 web pages on 179 unique websites. Cannabis was mentioned for the treatment of 151 different medical and health conditions, only four of the twenty most frequently mentioned conditions have received substantial empirical support for cannabis or cannabinoid treatment. Information content varied widely across sites, only a small proportion of sites included information on pharmacology, dosage, risks, and other aspects that are requirements for pharmaceutical drugs. Information provided was only moderately related to conclusions in the emerging scientific literature.

CONCLUSIONS

Given the rise in cannabis use within the U.S. and the reliance on the Internet as a source of information, considerable efforts are needed to provide accurate on-line cannabis education to minimize harms and maximize benefits for individuals and society.

Does cannabis complement or substitute alcohol consumption? A systematic review of human and animal studies

BACKGROUND

Whether alcohol and cannabis complement or substitute each other has been studied for over two decades. In the changing cannabis policy landscape, debates are moving rapidly and spill-over effects on other substances are of interest.

AIMS

update and extend a previous systematic review, by: (a) identifying new human behavioural studies reporting on substitution and/or complementarity of alcohol and cannabis, and (b) additionally including animal studies.

METHODS

We replicated the search strategy of an earlier systematic review, supplemented with a new search for animal studies. Search results were crossed checked against the earlier review and reference lists were hand searched. Findings were synthesised using a narrative synthesis.

RESULTS

Sixty-five articles were included (64 in humans, one in animals). We synthesised findings into categories: patterns of use, substitution practices, economic relationship, substance use disorders, policy evaluation, others and animal studies. Overall, 30 studies found evidence for substitution, 17 for complementarity, 14 did not find evidence for either, and four found evidence for both.

CONCLUSIONS

Overall, the evidence regarding complementarity and substitution of cannabis and alcohol is mixed. We identified stronger support for substitution than complementarity, though evidence indicates different effects in different populations and to some extent across different study designs. The quality of studies varied and few were designed specifically to address this question. Dedicated high-quality research is warranted.

In our war against the opioid epidemic, could 'weed' be a winner?

INTRODUCTION

The opioid epidemic has resulted in the deaths of millions of Americans and was declared a public health emergency in 2017. In response, many states have enacted policies and analyzed various interventions for harm reduction and overdose prevention, which have embraced limited success. With more states legalizing medical marijuana, another intervention of interest in pain management, much research has since focused on the potential for medical marijuana laws (MMLs) to curb the opioid epidemic. Nonetheless, marijuana legalization and its use for medical purposes has been a polarizing debate from ethical, social, and clinical perspectives.

AREAS COVERED

We examine evidence on the merits of medical marijuana to address its potential as a diversion from prescription painkillers. Additionally, we review the impact of MMLs on opioid-related outcomes. Furthermore, we provide multi-layered recommendations for future directions in the evaluation of medical marijuana and MMLs as potential mitigators of the opioid epidemic.

EXPERT OPINION

Despite limited and mixed evidence of efficacy, medical marijuana may still play an important role in addressing the opioid epidemic in the United States. Furthermore, we believe coordinated responses among the federal government, states, researchers, and patients are crucial in producing more robust evaluations of medical marijuana and MMLs.

The switch from one substance-of-abuse to another: illicit drug substitution behaviors in a sample of high-risk drug users

Background

Substitution can be defined as the consciously motivated choice to use one drug, either licit or illicit, instead of another, due to perceptions of cost, availability, safety, legality, substance characteristics, and substance attributions. Substitution represents a potential risk to drug users, mainly when substitutes are of higher potency and toxicity. This study offers a basic conceptualization of illicit substitution behavior and describes substitution patterns among users of two highly prevalent drugs of abuse-heroin and cannabis.

Methods

Here, 592 high-risk drug users undergoing pharmacological and psycho-social treatment were interviewed. Patients were asked questions about current drug use, lifetime substitution, and substitution patterns. Descriptive statistics, chi-square tests of independence, and multinomial logistic regressions were used to identify and test correlates of substitution patterns for heroin and cannabis.

Results

Of the 592 drug users interviewed, 448 subjects (75.7%) reported having substituted their preferred drug for another illicit substance. Interviews yielded a total of 275 substitution events reported by users of cannabis, and 351 substitution events reported by users of heroin. The most frequently reported substitution substances for responders who preferred heroin were illicit non-prescribed "street" methadone (35.9%), followed by oral and transdermal prescription opioids (17.7%). For responders who preferred cannabis, substitution for synthetic cannabinoid receptor agonists (33.5%) followed by alcohol (16.0%) were the most commonly reported. Age at onset-of-use (p < 0.005), population group (p = 0.008), and attending treatment for the first time (p = 0.026) were significantly associated with reported lifetime substitution. Past-year use of stimulants, heroin, hallucinogens, methylenedioxymethamphetamine (MDMA), and novel psychoactive substances were-at the 95% confidence level-also significantly associated with reported lifetime substitution. In multivariate analysis, the odds for methadone substitution among heroin users were significantly affected by age at onset-of-use, type of treatment center, and education. Odds for substitution for synthetic cannabinoid receptor agonists among cannabis users were significantly affected by age, population group, type of treatment center, and education.

Conclusion

Self-substitution behavior should be considered by clinicians and policymakers as a common practice among most drugusers. Substitution for street methadone provides evidence for the ongoing diversion of this substance from Opioid Maintenance Treatment Centers, while the prominence of substitution of synthetic cannabinoids among dual-diagnosis patients should be regarded as an ongoing risk to patients that needs to be addressed by clinicians. Analysis of additional substitution patterns should provide further valuable insights into the behavior of drugusers.

An intimate partner violence prevention intervention for men, women, and couples in Ethiopia: Additional findings on substance use and depressive symptoms from a cluster-randomized controlled trial

BACKGROUND

Intimate partner violence (IPV) is linked to substance use by male perpetrators and is associated with an increased risk of depression for women who experience violence. Unite for a Better Life (UBL) is a gender-transformative intervention delivered to men, women, and couples in Ethiopia; previous evidence demonstrated the intervention significantly reduced experience of and perpetration of IPV when delivered to men and led to more equitable household task-sharing when delivered to men and couples. The aim of this analysis is to assess engagement in the UBL intervention and to examine the relationship between random assignment to the intervention and men's past-year substance use and women's reported depressive symptoms as measured at the individual level.

METHODS AND FINDINGS

A sample of 64 villages in Gurague zone, Ethiopia, was randomly allocated to 4 arms (men's UBL, women's UBL, couples' UBL, or control). In each village, 106 households were randomly sampled, and households in the intervention arms were invited to participate in UBL, consisting of 14 sessions delivered by trained facilitators. Households in the control arm were offered a short educational session on IPV. Descriptive data on participant engagement in the intervention are reported, and outcomes assessed in an intention-to-treat (ITT) analysis include male use of substances (alcohol and khat) and women's depressive symptoms as measured by the Patient Health Questionnaire (PHQ-9). Results from both adjusted and unadjusted specifications are reported, the latter adjusting for baseline covariates including age, education level, marriage length, polygamy, socioeconomic status, months between intervention and endline, and the baseline level of the outcome variable. The baseline sample includes 6,770 respondents surveyed in 2014-2015, and follow-up data were available from 88% of baseline respondents surveyed in 2017-2018; the majority of respondents report no education, and 61% are Muslim. Respondents reported high attendance rates and engagement in the intervention. In addition, there was evidence of a significant reduction in frequent past-year alcohol intoxication self-reported by men (adjusted odds ratio [AOR] = 0.56, 95% CI 0.36-0.85, p = 0.007), and a significant increase in the probability of frequent khat use self-reported by men (AOR = 3.09, 95% CI 1.37-6.96, p = 0.007), both observed in the couples' UBL arm at 24 months' follow-up relative to the control arm. There was a significant increase in symptoms of moderate depression among women in the women's UBL arm only (AOR = 1.65, 95% CI 1.13-2.41, p = 0.010), again relative to the control arm. There was no evidence of shifts in symptoms of mild or severe depression. The primary limitation of this study is the reliance on self-reported data around sensitive behaviors.

CONCLUSIONS

The findings suggest that the UBL intervention was associated with a reduction in men's use of alcohol when delivered to couples, but there was no evidence of a decrease in reported symptoms of depression among women in any experimental arm, and some evidence of an increase in symptoms of moderate depression in the women's UBL arm. Further research should explore how to optimize IPV prevention interventions to target related risks of mental health and substance use.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02311699; Socialscienceregistry.org AEARCTR-0000211.