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Bahji A, Socias ME, Bach P, Milloy M. Implications of Cannabis Legalization on Substance-Related Benefits and Harms for People Who Use Opioids: A Canadian Perspective. Cannabis Cannabinoid Res 2023; 8:699-702. [PMID: 37001172 PMCID: PMC10623062 DOI: 10.1089/can.2023.0031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
Abstract
In 2018, Canada enacted the Cannabis Act, becoming only the second country (after Uruguay) to legalize the recreational consumption of cannabis. Although there is ongoing global disagreement on the risk-benefit profile of cannabis with increasing legalization in many parts of the world, the evidence of rising cannabis use prevalence postlegalization has been consistent. In contrast, postlegalization changes in various cannabis-related metrics have been inconsistent in Canada and other parts of the world. Furthermore, the implications of cannabis legalization on substance-related harms and benefits for people who use unregulated drugs, particularly opioids, remain unclear. Finally, although Canada did not legalize cannabis to address the opioid crisis, there is rising scientific and popular interest in the therapeutic potential of cannabis to mitigate opioid-related harms. This perspective highlights the implications of cannabis legalization on substance-related benefits and harms for people who use opioids, the current state of Canadian research, and suggestions for future directions.
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Affiliation(s)
- Anees Bahji
- Department of Psychiatry, University of Calgary, Calgary, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
- British Columbia Centre on Substance Use, Vancouver, Canada
| | - M. Eugenia Socias
- British Columbia Centre on Substance Use, Vancouver, Canada
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Paxton Bach
- British Columbia Centre on Substance Use, Vancouver, Canada
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - M.J. Milloy
- British Columbia Centre on Substance Use, Vancouver, Canada
- Department of Medicine, University of British Columbia, Vancouver, Canada
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Costiniuk C, MacCallum CA, Boivin M, Rueda S, Lacasse G, Walsh Z, Daeninck PJ, Margolese S, Mandarino E, Deol JK, Sanchez T, Bell AD. Why a distinct medical stream is necessary to support patients using cannabis for medical purposes. J Cannabis Res 2023; 5:25. [PMID: 37403136 DOI: 10.1186/s42238-023-00195-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 06/21/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND Since 2001, Canadians have been able to obtain cannabis for medical purposes, initially through the Access to Cannabis for Medical Purposes Regulations (ACMPR). The Cannabis Act (Bill C-45) came into force on October 17, 2018, replacing the ACMPR. The Cannabis Act enables Canadians to possess cannabis purchased from a licensed retailer without authorization for either medical or nonmedical purposes. The Cannabis Act is currently the guiding legislation which governs both medical and nonmedical access. The Cannabis Act contains some improvements for patients but is essentially the same as its previous legislation. Beginning in October 2022, the federal government is conducting a review of the Cannabis Act and is questioning whether a distinct medical cannabis stream is still required, given the ease of access to cannabis and cannabis products. Although there is overlap in the reasons for medical and recreational cannabis use, the distinct legislation of medical versus recreational use of cannabis in Canada may be under threat. MAIN BODY A large segment of the medical, academic, research, and lay communities agree that there is a need for distinct medical and recreational cannabis streams. Perhaps most importantly, separation of these streams is necessary to ensure that both medical cannabis patients and healthcare providers receive the required support needed to optimize benefits while minimizing risks associated with medical cannabis use. Preservation of distinct medical and recreational streams can help to ensure that needs of different stakeholders are met. For example, patients require guidance in the form of assessing the appropriateness of cannabis use, selection of appropriate products and dosage forms, dosing titration, screening for drug interactions, and safety monitoring. Healthcare providers require access to undergraduate and continuing health education as well as support from their professional organizations to ensure medical cannabis is appropriately prescribed. Although there are challenges in conducing research, as motives for cannabis use frequently straddle boundaries between medical versus recreational cannabis use, maintenance of a distinct medical stream is also necessary to ensure adequate supply of cannabis products appropriate for medical use, to reduce stigma associated with cannabis in both patients and providers, to help enable reimbursement for patients, to facilitate removal of taxation on cannabis used for medical purposes, and to promote research on all aspects of medical cannabis. CONCLUSION Cannabis products for medical and recreational purposes have different objectives and needs, requiring different methods of distribution, access, and monitoring. HCPs, patients, and the commercial cannabis industry would serve Canadians well to continue to advocate to policy makers to ensure the continued existence of two distinct streams and must strive to make ongoing improvements to the current programs.
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Affiliation(s)
- Cecilia Costiniuk
- Chronic Viral Illness Service/Division of Infectious Diseases, McGill University Health Centre, McGill Cannabis Research Centre and Research Institute of the McGill University Health Centre, Montreal, QC, H4A 3J1, Canada.
| | - Caroline A MacCallum
- Department of Medicine and Division of Palliative Care, University of British Columbia and Greenleaf Medical Clinic, Vancouver, BC, Canada
| | | | - Sergio Rueda
- Department of Psychiatry and Institute of Health Policy, Management and Evaluation, Centre for Addiction and Mental Health, Institute for Mental Health Policy Research and Campbell Family Mental Health Research Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Zach Walsh
- Department of Psychology, University of British Columbia, Kelowna, BC, Canada
| | - Paul J Daeninck
- Department of Internal Medicine, CancerCare Manitoba, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | - Shari Margolese
- Canadian Institutes of Health Research (CIHR) Canadian HIV Trials Network, Vancouver, BC, Canada
| | - Enrico Mandarino
- Canadian Institutes of Health Research (CIHR) Canadian HIV Trials Network, Vancouver, BC, Canada
- MJardin Canada, Toronto, ON, Canada
| | - Jagpaul Kaur Deol
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Tatiana Sanchez
- Department of Psychology, University of British Columbia, Kelowna, BC, Canada
| | - Alan D Bell
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
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Garg R, Shojania K, De Vera MA. The association between cannabis and codeine use: a nationally representative cross-sectional study in Canada. J Cannabis Res 2022; 4:49. [PMID: 36085170 PMCID: PMC9463740 DOI: 10.1186/s42238-022-00160-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 09/02/2022] [Indexed: 11/10/2022] Open
Abstract
Background Due to the growing use of cannabis for the purposes of pain relief, evidence is needed on the impact of cannabis use on concurrent analgesic use. Therefore, our objective was to evaluate the association between the use of cannabis and codeine. Methods We conducted a cross-sectional study using data from the nationally representative Canadian Tobacco, Alcohol and Drugs Survey (2017). The primary explanatory variable was self-reported use of cannabis within the past year. The outcome was the use of codeine-containing product(s) within the past year. We used multivariable binomial logistic regression models. Results Our study sample comprised 15,459 respondents including 3338 individuals who reported cannabis use within the past year of whom 955 (36.2%) used it for medical purposes. Among individuals who reported cannabis use, the majority were male (N = 1833, 62.2%). Self-reported use of cannabis was associated with codeine use (adjusted odds ratio [aOR] 1.89, 95% CI 1.36 to 2.62). Additionally, when limited to cannabis users only, we found people who used cannabis for medical purposes to be three times more likely to also report codeine use (adjusted odds ratio [aOR] 2.96, 95% CI 1.72 to 5.09). Discussion The use of cannabis was associated with increased odds of codeine use, especially among individuals who used it for medical purposes. Our findings suggest a potential role for healthcare providers to be aware of or monitor patients’ use of cannabis, as the long-term adverse events associated with concurrent cannabis and opioid use remain unknown.
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Ceasar RC, Kral AH, Simpson K, Wenger L, Goldshear JL, Bluthenthal RN. Factors associated with health-related cannabis use intentions among a community sample of people who inject drugs in Los Angeles and San Francisco, CA 2016 to 2018. Drug Alcohol Depend 2021; 219:108421. [PMID: 33301996 PMCID: PMC7856255 DOI: 10.1016/j.drugalcdep.2020.108421] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 11/10/2020] [Accepted: 11/11/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Cannabis motivations have been studied extensively among patients of medicinal cannabis dispensaries, but less is known about motivations in community samples of opioid-using people who inject drugs. Our objective is to describe cannabis use motivations associated with self-treatment of physical pain, emotional issues, and as an opioid substitute. METHODS Data come from 6-month follow-up interviews with people who inject drugs who participated in a study on the efficacy of an injection initiation prevention intervention in Los Angeles and San Francisco, California from 2016-18. The analytic sample consists of 387 people who inject drugs who reported past-month cannabis use. We developed multivariable logistic regression models by reported cannabis use motivations: physical pain relief, emotional problems, and opioid substitute. RESULTS The most common cannabis use motivations reported by people who inject drugs was to "get high," relieve physical pain and emotional problems, and reduce opioid use. In separate multivariate models, using cannabis for physical pain relief was associated with higher odds of using cannabis as a substitute for opioids; cannabis for emotional problems was associated with being diagnosed with depression; and cannabis as a substitute for opioids was associated with non-prescribed, non-injection methadone use. CONCLUSION People who inject drugs reported using cannabis for health-related motivations. This motivation aligns with health needs and suggests the acceptability of cannabis use for health reasons in this population. Studies to determine the medical effectiveness of cannabis products for these common health and mental health needs among people who inject drugs are needed.
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Affiliation(s)
- Rachel Carmen Ceasar
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, 2001 N. Soto Street, Los Angeles, CA, 90032, USA.
| | - Alex H Kral
- Behavioral Health Research Division, RTI International, 2150 Shattuck Avenue, Suite 800, Berkeley, CA, 94704, USA
| | - Kelsey Simpson
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, 2001 N. Soto Street, Los Angeles, CA, 90032, USA
| | - Lynn Wenger
- Behavioral Health Research Division, RTI International, 2150 Shattuck Avenue, Suite 800, Berkeley, CA, 94704, USA
| | - Jesse L Goldshear
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, 2001 N. Soto Street, Los Angeles, CA, 90032, USA
| | - Ricky N Bluthenthal
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, 2001 N. Soto Street, Los Angeles, CA, 90032, USA
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Vozoris NT, Pequeno P, Li P, Austin PC, Stephenson AL, O'Donnell DE, Gill SS, Gershon AS, Rochon PA. Morbidity and mortality associated with prescription cannabinoid drug use in COPD. Thorax 2020; 76:29-36. [DOI: 10.1136/thoraxjnl-2020-215346] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/11/2020] [Accepted: 08/25/2020] [Indexed: 01/18/2023]
Abstract
IntroductionRespiratory-related morbidity and mortality were evaluated in relation to incident prescription oral synthetic cannabinoid (nabilone, dronabinol) use among older adults with chronic obstructive pulmonary disease (COPD).MethodsThis was a retrospective, population-based, data-linkage cohort study, analysing health administrative data from Ontario, Canada, from 2006 to 2016. We identified individuals aged 66 years and older with COPD, using a highly specific, validated algorithm, excluding individuals with malignancy and those receiving palliative care (n=185 876 after exclusions). An equivalent number (2106 in each group) of new cannabinoid users (defined as individuals dispensed either nabilone or dronabinol, with no dispensing for either drug in the year previous) and controls (defined as new users of a non-cannabinoid drug) were matched on 36 relevant covariates, using propensity scoring methods. Cox proportional hazard regression was used.ResultsRate of hospitalisation for COPD or pneumonia was not significantly different between new cannabinoid users and controls (HR 0.87; 95% CI 0.61–1.24). However, significantly higher rates of all-cause mortality occurred among new cannabinoid users compared with controls (HR 1.64; 95% CI 1.14–2.39). Individuals receiving higher-dose cannabinoids relative to controls were observed to experience both increased rates of hospitalisation for COPD and pneumonia (HR 2.78; 95% CI 1.17–7.09) and all-cause mortality (HR 3.31; 95% CI 1.30–9.51).ConclusionsNew cannabinoid use was associated with elevated rates of adverse outcomes among older adults with COPD. Although further research is needed to confirm these observations, our findings should be considered in decisions to use cannabinoids among older adults with COPD.
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