By DAVE SCHMADER
Philippe Lucas has deep roots in Canada’s cannabis culture. After co-founding the Vancouver Island Compassion Society medical dispensary in 1999, Lucas applied himself to cannabis science, working as a graduate researcher with the Center for Addictions Research of British Columbia and serving as founding board member of both the Multidisciplinary Association of Psychedelic Studies Canada and the Canadian Drug Policy Coalition. In 2013, he received the Queen Elizabeth II Diamond Jubilee Medal for his research on medical cannabis.
(Full disclosure/fun fact: He’s also Vice President of Patient Advocacy at Tilray, the cannabis production company owned by Privateer Holdings, which also owns Leafly.)
Most recently, Lucas is the author of a new study: “Rationale for cannabis-based interventions in the opioid overdose crisis,” published last month in the Harm Reduction Journal. In the study, Lucas lays out a variety of roles that cannabis might play in combatting the opioid epidemic, which currently kills 38,000 people in the U.S. and Canada each year and ranks as the leading cause of death among Americans under 50.
His study added an important perspective to the growing body of evidence supporting the notion of cannabis as healing tool in the opioid crisis. That idea is quickly moving into mainstream thought, as we’ve seen recently with the public pronouncements of Utah Sen. Orrin Hatch and, just this week, Dr. Oz.
Over the phone from his office in Nanaimo, Lucas let me interrogate him about specifics of the study.
Dave Schmader: What inspired you to undertake this study?
Philippe Lucas: Whether it’s medical use or recreational use, cannabis appears to be having an impact on the rates of opioid abuse. This study is a summation of the evidence, and I’ve taken that summation to suggest three opportunities for cannabis to intervene in the opioid crisis.
And those are…?
First is introduction—if physicians start recommending the use of medical cannabis prior to introducing patients to opioids, those patients that find cannabis to be a successful treatment for their chronic pain might never have to walk down the very tricky path of opioid use that all too often leads to abuse or overuse or overdose.
The second opportunity is reduction, for those patients who are successfully using opioids in the treatment of their chronic pain or other conditions but are worried about increasing their use of opioids over time. The evidence suggests you can introduce cannabis as an adjunct treatment and reduce the cravings for opioids, therefore potentially steering people away and reducing the risk of opioid overdose and opioid dependence.
The third part is cessation. Once individuals have become dependent on opioids and they recognize that dependence and are seeking treatment for it through opioid replacement therapy like methadone and suboxone, you can potentially introduce cannabis as an adjunct treatment to increase the success rate of the methadone or suboxone treatment. The reason this point is so important is that when people with an opioid dependence fail out of treatment, that’s the period where they become the most vulnerable to potential overdose. Replacement therapy has failed, they’re at their most vulnerable, and they go back to the illicit drug market, potentially risking overdose.
A key concept in the study is the “substitution effect.”
Yes. The substitution effect is an economic concept that suggests that the use of one substance never stands alone. In fact, the use of one substance can affect the use of another. When it comes to psychoactive substances, the use of a substance can be affected by changes in price, changes in legality or regulatory access, or changes in the product itself in terms of potency. And that can really affect the use of another drug.
A 2014 study showed that in medical cannabis states, there was a 25 percent reduction in opioid overdose deaths compared to neighboring states that didn’t have medical cannabis programs. There’s a growing body of research showing that simply making medical cannabis available in a number of US states and in Canada has reduced rates of not just opioid use, but also the use of alcohol, tobacco, and illicit substances,
often leading to total abstinence of those substances. So we’re looking at cannabis as a potential therapeutic agent, but also as a harm reduction agent when it comes to problematic substance use. This evidence suggests cannabis could be an exit drug to problematic substance use and addiction.
In the study you write, “Cannabis augments the pain-relieving potential of opioids and can re-potentiate their effects.” Tell me about re-potentiation.
Research suggests that when you use cannabis alongside opioids in the treatment of chronic pain, you seem to get a synergistic effect—a greater effect than you might have if each was taken individually. People who have been using opioids for some time sometimes have to increase their dose, and cannabis presents another option for physicians, so instead of increasing the dose of opioids they can instead prescribe medical cannabis as an adjunct treatment in order to keep the patient at a lower dose of opioids, thereby reducing the risk of overdose.
Another study quote: “[I]t would seem logical to seek to develop policies and associated education strategies to increase physician support for cannabis for therapeutic purposes in the treatment of chronic pain.” This does seem logical. What are the chances of it happening?
Right now we’re facing this tremendous public-health threat around the opioid overdose crisis. Opioid overdose is the most common cause of accidental death in Canada and the US right now. The over-prescription of opioids seems to be leading the way, in that four out of five people currently injecting opioids say that they started by using prescription opioids. There’s an oversaturation of the market and an over-availability on the black market.
I think that if we can shift prescription patterns by physicians—so that instead of first prescribing opioids and then, if those opioids fail, moving on to medical cannabis—we can modernize those policies and instead focus on introducing medical cannabis first. That’s based on all the available evidence, which indicates that it’s far less harmful than prescription opioids in terms of dependence and risk of overdose.
Right now in Canada and in US states with medical marijuana, physicians are encouraged to prescribe opioids first and if those don’t work, cannabis is considered as a third- or fourth-line treatment option. We need to flip that around and make cannabis the second-line treatment option and move opioids to third or fourth options if indeed cannabinoids are not successful.