Recreational substances

Abstract – Background: Ecological research suggests that increased access to cannabis may facilitate reductions in opioid use and harms, and medical cannabis patients describe the substitution of opioids with cannabis for pain management. However, there is a lack of research using individual-level data to explore this question. We aimed to investigate the longitudinal association between frequency of cannabis use and illicit opioid use among people who use drugs (PWUD) experiencing chronic pain.

Methods and findings: This study included data from people in 2 prospective cohorts of PWUD in Vancouver, Canada, who reported major or persistent pain from June 1, 2014, to December 1, 2017 (n = 1,152). We used descriptive statistics to examine reasons for cannabis use and a multivariable generalized linear mixed-effects model to estimate the relationship between daily (once or more per day) cannabis use and daily illicit opioid use. There were 424 (36.8%) women in the study, and the median age at baseline was 49.3 years (IQR 42.3–54.9). In total, 455 (40%) reported daily illicit opioid use, and 410 (36%) reported daily cannabis use during at least one 6-month follow-up period. The most commonly reported therapeutic reasons for cannabis use were pain (36%), sleep (35%), stress (31%), and nausea (30%). After adjusting for demographic characteristics, substance use, and health-related factors, daily cannabis use was associated with significantly lower odds of daily illicit opioid use (adjusted odds ratio 0.50, 95% CI 0.34–0.74, p < 0.001). Limitations of the study included self-reported measures of substance use and chronic pain, and a lack of data for cannabis preparations, dosages, and modes of administration.

Conclusions: We observed an independent negative association between frequent cannabis use and frequent illicit opioid use among PWUD with chronic pain. These findings provide longitudinal observational evidence that cannabis may serve as an adjunct to or substitute for illicit opioid use among PWUD with chronic pain.

[Discussion] A recent study analyzed longitudinal data from a large US national health survey and found that cannabis use increases, rather than decreases, the risk of future non-medical prescription opioid use in the general population, providing important evidence to challenge the hypothesis that increasing access to cannabis facilitates reductions in opioid use. The findings of our study reveal a contrasting relationship between cannabis use and frequency of opioid use, possibly due to inherent differences in the sampled populations and their motivations for using cannabis. Within the current study population, poly-substance use is the norm; HIV and related comorbidities are common; and pain management through prescribed opioids is often denied, increasing the likelihood of non-medical opioid use for a medical condition. Furthermore, our study is largely focused on this relationship in the context of pain (i.e., by examining individuals with self-reported pain and accounting for intensity of pain). Our findings align more closely with those of a recent study conducted among HIV-positive patients living with chronic pain, in which the authors found that patients who reported past-month cannabis use were significantly less likely to be taking prescribed opioids. While this finding could have resulted from prescription denial associated with the use of cannabis (or any illicit drug), we show that daily cannabis users in this setting were slightly more likely to have been prescribed a pain medication at baseline, and adjusting for this factor in a longitudinal multivariable model did not negate the significant negative association of frequent cannabis use with frequent illicit opioid use.

The idea of cannabis as an adjunct to, or substitute for, opioids in the management of chronic pain has recently earned more serious consideration among some clinicians and scientists. A growing number of studies involving patients who use cannabis to manage pain demonstrate reductions in the use of prescription analgesics alongside favourable pain management outcomes. For example, Boehnke et al. found that chronic pain patients reported a 64% mean reduction in the use of prescription opioids after initiating cannabis, alongside a 45% mean increase in self-reported quality of life. Degenhardt et al. found that, in a cohort of Australian patients on prescribed opioids for chronic pain, those using cannabis for pain relief (6% of patients at baseline) reported better analgesia from adjunctive cannabis use (70% average pain reduction) than opioid use alone (50% average reduction). However, more recent high-quality research has presented findings to question this narrative. For example, in the 4-year follow-up analysis of the above Australian cohort of pain patients, no significant temporal associations were observed between cannabis use (occasional or frequent) and a number of outcomes including prescribed opioid dose, pain severity, opioid discontinuation, and pain interference. Thus, several other explanations for our current results, aside from an opioid-sparing effect, are worthy of consideration.

[..] We observed that daily cannabis users endorsed intentional use of cannabis for a range of therapeutic purposes that may influence pain and pain interference. After pain, insomnia (43%) and stress (42%) were the second and third most commonly reported motivations for therapeutic cannabis use among daily cannabis users. The inability to fall asleep and the inability stay asleep are common symptoms of pain-causing conditions, and experiencing these symptoms increases the likelihood of opioid misuse among chronic pain patients. The relationship between sleep deprivation and pain is thought to be bidirectional, suggesting that improved sleep management may improve pain outcomes. Similarly, psychological stress (particularly in developmental years) is a well-established predictor of chronic pain and is also likely to result from chronic pain. Thus, another possible explanation for our finding is that cannabis use substitutes for certain higher-risk substance use practices in addressing these pain-associated issues without necessarily addressing the pain itself.

Frequency of cannabis and illicit opioid use among people who use drugs and report chronic pain: A longitudinal analysis, PLOS Medicine, 2019.11.19

“Of all the substances people intoxicate themselves with, alcohol is the least restricted and causes the most harm. Many illegal drugs are more dangerous to those who use them, but are relatively hard to obtain, which limits their impact. In contrast, alcohol is omnipresent, so far more people suffer from its adverse effects. In 2010 a group of drug experts scored the total harm in Britain caused by 20 common intoxicants and concluded that alcohol inflicted the greatest cost, mostly because of the damage it does to non-consumers such as the victims of drunk drivers.

No Western country has banned alcohol since America repealed Prohibition in 1933. It is popular and easy to produce. Making it illegal enriches criminals and starts turf wars. In recent years governments have begun legalising other drugs. Instead, to limit the harm caused by alcohol, states have tried to dissuade people from drinking, using taxes, awareness campaigns and limits on where, when and to whom booze is sold.

[..] Producers are ready to fend off regulators. In 1999 alcohol firms invested half as much on lobbying in America as tobacco firms did. Today they spend 31% more.”

Alcohol firms promote moderate drinking, but it would ruin them

Excerpt – “What most fail to realize is that we have a dual crisis in this country,” said Dr. Jeffrey Gudin, a senior medical advisor for Quest and a pain management specialist at Englewood Hospital and Medical Center in New Jersey. “There is no question that people misuse substances that make them feel good, but there is also a crisis of chronic pain, of which there is no cure.”

[..] More than 70% of doctors said that although there will likely be a decrease in opioid-related deaths, more patients will not have their pain properly managed.

Meanwhile, gabapentin [..] was detected in more than half of opioid overdose deaths, according to the CDC. Quest’s data show that 13.4% of patient test results showed non-prescribed gabapentin in 2018, up from 9.6% in 2017. Gabapentin trailed only marijuana and alcohol at 14% each.

Gabapentin is one of only three drug groups for which misuse, often improper combinations of drugs, increased from 2017 to 2018. The other two were alcohol and nonprescribed fentanyl. Physicians were also concerned about the abuse of benzodiazepines and amphetamines.

“Pain patients have learned if their psychiatrist gives them Valium, then they don’t tell their doctor because they won’t give them opioids,” Gudin said. Part of it is on the patient; part is on the clinician, he said, adding that Quest has been promoting a major educational campaign about drug mixing.

Non-opioid medication on the rise as U.S. combats opioid crisis (2019.10.16)

“The opioid overdose crisis has claimed more than 400,000 lives in the United States since 1999. As part of efforts to reduce overdose deaths and increase enrollment in treatment, lawmakers in some states are contemplating enacting or expanding emergency hold laws that permit some patients with severe substance use disorder to be involuntarily detained for short-term observation and, in some cases, treatment. [..]

Emergency hold laws for mental illness, which exist in every state, all require some finding of dangerousness, either to self or to others. Since emergency hold laws for substance use disorder would presumably rely on this standard as well, a crucial question is whether these holds would attenuate the dangerousness, particularly to people with substance use disorders themselves, that would justify restricting individual liberty.

The increase in opioid overdose deaths over the past two decades is largely the result of unintentional overdoses, not suicides. It’s not clear that emergency holds would prevent these deaths. Certainly, people who experience an overdose are at high risk for subsequent overdose and death. In the year after a nonfatal opioid overdose, rates of fatal overdose range from 1% to 5% and about one in five people has another nonfatal overdose. Research doesn’t support the notion that short-term treatment during involuntary holds would reduce these risks, however. In cases in which people with substance use disorder express suicidal intent or have coexisting psychiatric disorders that create imminent safety concerns, existing mental health laws provide well-established mechanisms for involuntary observation and treatment.

[..] The limited research evaluating involuntary treatment for substance use disorders is inconclusive, and no data exist in support of emergency holds. Furthermore, forced abstinence during emergency holds may increase the risk of overdose once a person is released, just as people with opioid use disorder who don’t receive medication treatment during incarceration or inpatient detoxification have continued cravings for opioids but lower tolerance to their effects.

[..] Furthermore, fear of involuntary holds may undermine patients’ trust in clinicians, increase skepticism of the medical system, and deter patients from voluntarily seeking care after an overdose or for injection-related complications (e.g., soft-tissue infections, HIV, hepatitis C, and vascular injuries). Policymakers’ help is needed to address barriers to evidence-based treatment and other factors that disproportionately affect groups already subject to social injustices.”

Will Emergency Holds Reduce Opioid Overdose Deaths? (2019.10.16)

“Efforts to track the cause of the lung illnesses have been hampered by the fact that THC-based products largely fall into a regulatory vacuum, and relaxed laws in many states have enabled an illicit trade. While marijuana is still illegal at the federal level, nearly three dozen states permit medicinal use, and 11 states and the District of Columbia have fully legalized it.

The F.D.A.’s authority over THC is considered a gray area of law. A handful of cannabis-derived drugs have been approved, and the F.D.A. is talking to other agencies about expanding its reach.

Nearly 1,300 people, disproportionately young, have been sickened from vaping THC, nicotine or both. At least 29 have died.

It often takes a public health crisis for the federal government to enact major change, said Dr. Califf, the former F.D.A. commissioner.”

E-Cigarettes Went Unchecked in 10 Years of Federal Inaction (2019.10.14)

“Close to half of U.S. adults, 46%, have dealt with substance abuse problems in their family: 18% have had just alcohol problems and 10% have had just drug problems, while 18% have experienced both. [..]

36% of Americans reported that drinking has been a cause of trouble in their family and 28% said the same of drug abuse. [..]

Whether the long-term rise in reported drinking problems reflects real changes, greater respondent awareness of drinking problems or greater willingness to report them isn’t clear. One thing is clear: Drinking isn’t more common today than it was then, with similar percentages of Americans in the 1940s and today reporting that they drink alcohol — around 65%.”

Substance Abuse Hits Home for Close to Half of Americans (2019.10.14)