Cannabis as a substitute for alcohol and other drugs: A dispensary-based survey of substitution effect in Canadian medical cannabis patients

This article examines the subjective impact of medical cannabis on the use of both licit and illicit substances via self-report from 404 medical cannabis patients recruited from four dispensaries in British Columbia, Canada. The aim of this study is to examine a phenomenon called substitution effect, in which the use of one product or substance is influenced by the use or availability of another.

Addiction Research and Theory,Early Online: 1–8
Copyright ß 2012 Informa UK Ltd.
ISSN: 1606-6359 print/1476-7392 online
DOI: 10.3109/16066359.2012.733465
Cannabis as a substitute for alcohol and other drugs: A
dispensary-based survey of substitution effect in Canadian
medical cannabis patients
Philippe Lucas1, Amanda Reiman2, Mitch Earleywine3, Stephanie K.McGowan4,
Megan Oleson5, Michael P.Coward6*, & Brian Thomas7
1Centre for Addictions Research of BC, PO Box 1700 STN CSC, Victoria, BC V8W 2Y2, Canada,2School of
Social Welfare,University of California,120 Haviland Hall,Berkeley 94720,CA, USA, 3Department of
Psychology,University at Albany,State University of New York,1400 Washington Ave,Albany 12222,NY,
USA, 4Vancouver Island Compassion Society,853 Cormorant St.,Victoria,BC V8W 1R2,Canada,5British
Columbia Compassion Club Society,2995 Commercial Drive,Vancouver,BC V5N 4C8,Canada,6The
Vancouver Dispensary Society,880 East Hastings,Vancouver,BC V6A 1R6,Canada,and7Green Cross
Society of BC,2127 Kingsway,Vancouver,BC V5N 2T4,Canada
(Received 2 May 2012; accepted 20 September 2012)
Background:This article examines the subjective
impact of medical cannabis on the use of both licit
and illicit substances via self-report from 404
medical cannabis patients recruited from four dis-
pensaries in British Columbia,Canada.The aim of
this study is to examine a phenomenon called
substitution effect,in which the use of one product
or substance is influenced by the use or availability
of another.
Methods:Researchers teamed with staff representa-
tives from four medical cannabis dispensaries
located in British Columbia,Canada to gather
demographic data of patient-participants as well as
information on past and present cannabis,alcohol
and substance use. A 44-question survey was used to
anonymously gather data on the self-reported
impact of medical cannabis on the use of other
substances.
Results:Over 41% state that they use cannabis as a
substitute for alcohol (n ¼ 158),36.1% use cannabis
as a substitute for illicit substances (n ¼ 137),and
67.8% use cannabis as a substitute for prescription
drugs (n ¼ 259).The three main reasons cited for
cannabis-related substitution are ‘‘less withdrawal’’
(67.7%),‘‘fewer side-effects’’ (60.4%),and ‘‘better
symptom management’’ suggesting that many
patients may have already identified cannabis as an
effective and potentially safer adjunct or alternative
to their prescription drug regimen.
Discussion:With 75.5% (n ¼ 305) of respondents
citing that they substitute cannabis for at least one
other substance, and in consideration of the growing
number of studies with similar findings and the
credible biological mechanisms behind these results,
randomized clinical trials on cannabis substitution
for problematic substance use appear justified.
Keywords: Cannabis,marijuana,dispensary,substitution
effect,addiction
INTRODUCTION
Background
Cannabis is the mostpopularillicit substance in the
world (UNDCP, 2001); however, despite the high rate of
recreationaluse and over5000 yearsof therapeutic
applications,this planthas resulted in relatively few
serious negative physical or social impacts beyond the
consequences associated with legal prohibitions on its
use.(Grinspoon & Bakalar,1993).However,the ther-
apeutic use of cannabis remains highly controversial,
and only a few Western nations have introduced policies
or programs to allow legal access to medical cannabis.
Correspondence: Philippe Lucas,Centre for Addictions Research of BC,PO Box 1700 STN CSC,Victoria,BC V8W 2Y2,Canada.
Tel: [phone].E-mail: [e-mail]
*All contact for The Vancouver Dispensary Society should be directed to Dori Dempster,Executive Director.
1
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Although Canada currently allows for limited access
to medicalcannabisthrough the federally-regulated
Marihuana MedicalAccessDivision (MMAD), this
court-ordered program has been the source ofmuch
criticism by end-usersand advocates,and hasbeen
found by courts to be unconstitutional in a number of
decisionsfor unnecessarily limiting accessto legal
protection and a safe supply of cannabis. In response to
both community needs and ineffective or non-existent
federalmedicalcannabispolicies,community-based
medicalcannabisdispensarieshave emerged aspri-
mary suppliers of medical cannabis in both Canada and
in a number of the US states thathave legalized the
medical use of cannabis.
Community-based medicalcannabisdispensaries,
often called compassion clubs,supply cannabisfor
therapeuticuse upon a valid recommendationor
confirmation ofdiagnosis from a licensed healthcare
practitioner,and reflecta patient-centered strategy to
alleviate the suffering of critically and chronically ill
Canadians who might benefit from the medical use of
cannabis (Belle-Isle, 2006; Lucas, 2008, 2009; Reiman,
2006,2009).
During the late 1980s,as rates ofHIV and AIDS
began to rise in San Francisco,a few underground
dispensaries began offering a safe source of cannabis to
those needing it for medical purposes were established
by compassionate people living with HIV/AIDS and
drug policy reform activists.With the successful
passagein 1996 of a stateballot initiativecalled
‘‘Proposition 215,’’California became the firstUS
state to allow for the legal medical use and distribution
of cannabis.Within a few weeksdozensof these
‘‘compassion clubs’’ opened,and although they often
had varied policies and practices,their common goal
was facilitating access to a safe supply of cannabis for
medical users (Grinspoon, 1999). Since then, over 1000
community-based medicalcannabis dispensaries have
opened up in California (Los Angeles Times,2009),
and it is estimated thatthey currently supply over
250,000 state authorized patients(Gieringer,2006).
Similar organizations have emerged all over the world,
and in Canada and the US these dispensaries remain the
main source ofcannabis-based medicinesfor thera-
peutic use.
There are a dozen or so well-established compassion
clubsor societiesin Canada (and according to the
Canadian Association of Medical Cannabis
Dispensaries,perhaps54 in total),1 the oldestand
largestof which is Vancouver’sBritish Columbia
CompassionClub Society(BCCCS). The BCCCS
opened in 1997 and now serves over 7000 members.
Taking a holistic approach to health,this non-profit
organizationoperatesa WellnessCentreoffering
alternative treatments such as massage,acupuncture,
counseling,and herbal and aromatherapy at a reduced
cost to members of the society.The Vancouver Island
Compassion Society (VICS),a registered non-profit
society in B.C. since October 1999, uses its knowledge
and experience of cannabis and its therapeutic proper-
ties to implementan extensive research agenda,and
over the last10 yearshas been involved in more
peer-reviewed medicinalcannabisresearch than any
other organization in Canada (Lucas,2008).
Communities, law enforcement, and criminal courts
across Canada have shown supportand tolerance for
compassion clubsthat self-regulateto ensuretheir
services are strictly formedicalpurposes (Belle-Isle,
2006; Lucas, 2002,2008, 2009,2012).However,
Canadiandispensariescontinueto operatewithout
legalsanction orprotection,and to date very little
research has been conducted on this rapidly expanding
patient community to determine the impact of medical
cannabis on the use of other substances or the quality o
life of individual end-users.
Substitution effect and addiction
Substitution effect is an economic theory that suggests
that variationsin the availabilityof one product
(through changes in cost or social policy, for example),
may affect the use of another:
Within a behavioraleconomic framework,reinforcerinter-
actions are classified into multiple categories; two commod-
ities may be ‘‘substitutes’’ for one another (e.g., two forms of
opioid drugs);they may be ‘‘complementary,’’ whereby the
value of one is enhanced by consumption of the other; or they
may be ‘‘independent,’’ such that the reinforcing functions of
one are notaltered by the presence or absence of the other
(Hursh,Galuska,Winger,& Woods,2005,p. 24).
Changes in the use of cannabis (whether for medical
or recreationaluse)in regardsto the use of other
substancescan be the resultof (a) economic shifts
affecting end-usercosts;(b) shiftsin policy which
effectavailability;(c) legalshifts thataffectcriminal
risk and associated repercussions; or (d) psychoactive/
pharmacologicalsubstitution.In regards to psychoac-
tive substitution,Hursh et al. (2005)suggestthat
‘‘pharmacologicaltherapies for the treatmentof drug
abuse can also be conceptualized as alternative com-
modities that either substitute for illicit drug use (e.g.,
agonisttherapy) or reduce the potency of illicitdrugs
directly (e.g.,narcotic antagonist therapy)’’ (p.25).
Perhaps the best example of deliberate psychoactive
substitution is the common prescription use of meth-
adone as a substitute to injection heroin use. However,
as suggested above, not all psychoactive substitution is
the result of a deliberatedecisionmade on an
individualbasis.At the population level,it is often
the unintended resultof public policy shifts or other
social changes,such as cost or availability.
In an examination ofhospitaldrug episodesin
13 US states thatdecriminalized the personalrecrea-
tionaluse of cannabisin the 1970s,Model (1993)
found thatusers shifted from using harderdrugs to
marijuana after its legal risks were decreased. Findings
from Australia’s 2001 National Drug Strategy
Household Survey (Aharonovichet al., 2002)
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specificallyidentify substitutioneffect, indicating
56.6% of heroin users substituted cannabis when their
substance of choice was unavailable.The survey also
found that31.8% ofpeople who use pharmaceutical
analgesicsfor non-medicalpurposesreported using
cannabiswhen pain-killerswere notavailable.This
evidence strongly suggests that the increased availabil-
ity of cannabis (through a reduction ofpenalties or
actual regulated, legal access) might lead to a reduction
in the use of opiates and pharmaceutical analgesics and
the associated personal, social and public health harms
and costs.
Substitutionamonga medicalCannabispatient
sample was recently documented in a few studies by
Reiman (2006,2009).In a sample of130 medical
Cannabispatientsfrom California,24 had reported
previousalcoholtreatment.Concerning theuse of
Cannabis as a substitute for alcohol, illicit or prescrip-
tion drugs,Reiman (2006)observed that50% of the
sample reported using Cannabisas a substitute for
alcohol,47% for illicitdrugs,and 74% using itas a
substitutefor prescriptiondrugs. The two most
common reasonsreported forusing Cannabisas a
substitute were fewerside effects and betteroverall
symptom management.
These results were replicated in a 2009 study of 350
medicalCannabis patients in California.53% percent
reported being currentalcoholconsumersand 11%
reported using a drug other than Cannabis in the past
30 days.Forty percent reported having used Cannabis
as a substitute for alcohol, 26% as a substitute for illicit
drugs,and 66% as a substitute for prescription drugs.
The most common reasons for substitution were again
cited as less adverse side effects and better symptom
management with Cannabis (Reiman,2009).
Additionally,an analysis of 1655 potential medical
Cannabispatientsseeking recommendationsfrom a
clinic in California revealed that 13.2% reported using
Cannabisas a substitutefor alcohol and 50.8%
reported using Cannabis as a substitute for prescription
drugs (Nunberg,Kilmer,Pacula,& Burgdorf,2011).
CANNABIS AND PROBLEMATIC
SUBSTANCE USE
While the illegal status of Cannabis across most of the
world has madeclinical trials on Cannabisas a
treatment for problematic substance use nearly impos-
sible, a number of studies on both humans and animals
suggestthatthe cannabinoid system plays a role in
dependenceand addictionto both licit and illicit
substances.For example,research showsthatbeha-
viouraleffects and motivational responses induced by
nicotine can be modulated by the endocannabinoid
system (Balerio, Aso, & Maldonado, 2006; Damaj and
Lichtman, 2011; Muldoon, Lichtman, & Damaj, 2011).
Furthermore,research by Blumeet al. (2011)and
Ramesh et al.(2011) suggests that cannabinoid recep-
tors mightinterruptsignaling in the opioid receptor
systems,affectingboth cravingsfor opiatesand
withdrawal severity.
Additionally,a study by the New York State
Psychiatric Institute on people with cocaine depen-
dence with comorbid Attention-DeficitHyperactivity
Disorderfound thatCannabis users were more suc-
cessfulthan other patients in abstaining from cocaine
use (Levin,2006).An earlier study by LabigaliniJr,
Rodrigues, and Da Silveira (1999) also noted this effect
on peoplewith a dependenceon crack cocaine,
reportingthat 68% of the 25 subjectswho self-
medicated with Cannabis in order to reduce cravings
were able to give up crack altogether.Researchers
theorize thatthis phenomenon is both biologicaland
psychological.Addictionto stimulantsresultin a
declinein the cerebralactivity involving serotonin
transmitters,which is believed to resultin increased
impulsivenessand craving. Cannabinoidsact as
seratoninenergicagonists,and as serotoninlevels
increase,impulsiveness and craving decline.Reports
from study subjectsalso suggestthatthe ritualof
preparingCannabisto smoke helpedreducethe
habituated psychologicaldependence associated with
the preparation of crack cocaine.
Furthermore,recentresearch by Maitra,Bortoff,
Pan, Reggio, and Seltzman(2011) suggeststhat
cannabinoids mightprotectthe liver from the effects
of heavy alcohol use, and researchby Liput,
Pendergast,and Nixon (2011) and Devkotaand
Mukhopadhyay(2011) suggestsa neuroprotective
function ofcannabinoids during alcoholwithdrawal,
and asa resultof heavy alcoholuse.Additionally
methodsfor administering THC,such astransder-
mally, for the treatmentof alcoholism hasbeen
explored by Howard, Banks, Golinski, and
Stinchcomb (2011).
Finally, exploratory research suggests that Cannabis
use doesnot interfere with formalsubstance abuse
treatment.Data from the California Outcomes
MeasurementSystem (CalOMS)were compared for
medical (authorized) marijuana users (n ¼ 18) and non-
marijuanausers who were admittedto a public
substanceabusetreatmentprogram in California.
Behavioraland socialtreatmentoutcomesrecorded
by clinical staff at dischargeand reported to the
California Department of Alcohol and Drug Programs
were assessed for both groups, and although the sample
was small,Cannabis use did not seem to compromise
substance abuse treatmentamongstthe medicalmar-
ijuana using group,who (based on these preliminary
data) fared equal to or betterthan non-medical
marijuana users in severalimportantoutcome catego-
ries (e.g., treatmentcompletion,criminal justice
involvement,medical concerns) (Schwartz,2010).
METHODOLOGY
For this community-based study researchersteamed
with a staff representative from four medical cannabis
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dispensaries in British Columbia,Canada – three in
Vancouverand one in Victoria – in orderto gather
demographic data as wellas information on pastand
present medical cannabis, alcohol and substance use of
400þ patient-participants.Our goal was to assess
the self-reported impact of medical cannabis on the use
of other substances,includingbut not limited to
reductionsin patternsof problematic substance use,
in order to examine a phenomenon called substitution
effect.
The specific hypotheses investigated in this study
include:
(1) Whether or not the use of medical cannabis affects
the use of other substances according to the self-
assessment of patient-participants.
(2) Whetheror not these changesin substance use
patterns result in net reductions or increases in the
use of licit or illicit drugs.
(3) Whether or not these changes can be attributed to
‘‘substitution effect.’’
The four participating dispensaries are the BCCCS,
the VICS, The Green Cross Society of British
Columbia (GCSBC),and the VancouverDispensary
Society (VDS).
The BCCCS first opened its doors in 1997, and now
serves over7300 patient-members.The GCSBC was
founded in 2005,and serves 1182 patients.The VDS
was founded in 2008,and currently serves over 3700
patients.While these three dispensaries are located in
Metro Vancouver BC (pop.approx.two million),the
VICS – which was founded in 1999 and serves 1400
patients – is located in the greater Victoria area (pop.
approx.250,000).
The study was sponsoredby the participating
dispensaries,and ethicsapprovalwas soughtand
received from InstitutionalReview Board Services
(IRBS). Primary InvestigatorPhilippe Lucas MA
trained a staff member/co-investigator in each facility
on how to dispense,gather,and track the anonymous
survey instrument,which was filled outand collected
on-site.The survey waslargely based on a similar
instrumentcreated by co-researcherAmanda Reiman
PhD for a study that took place at the Berkeley-based
BerkeleyPatientGroup (Reiman,2009),but was
modifiedby Lucas to makeit applicableto any
dispensary patient population.
Each dispensary had a goal of gathering a minimum
of 100 surveys, and in order to ensure the randomness
of the survey population,the co-investigatorsalso
tracked how many dispensary clients decline to partic-
ipate in the study.Ultimately,a total 32 potential
patient-participants chose not to take this survey when
approached by dispensary staff.Data entry ofcom-
pleted surveyswas then done by Mitch Earleywine
PhD (State University ofNew York),and data were
analyzed in SPSS by Reiman,who also calculated
frequencies.
RESULTS
Demographics
The total survey sample for this study was 404 medical
cannabis patients between the ages of 17–71 registered
with at least one of the four participatingB.C.-
baseddispensaries.The samplewas 67.1% male
(n ¼ 259),71.6% Caucasian(n ¼ 275)and 12.5%
First Nations(n ¼ 48),with a mean ageof 44.12.
Ethnicitydiffers significantlybasedon dispensary
location (p < 0.05).Caucasians are over-represented at
VDS and VICS and under-represented at Green Cross.
First Nationspatientsare over-represented atGreen
Cross and African Americansare over-represented
at VDS.
In regards to maritalstatus,55.3% reportthatthey
are single (n ¼ 213),15.3% are married,13.2% are
divorced and 12.7% have a domestic partner. Eighteen
percentstate thatthey have a full-time job (n ¼ 71),
while 14.3% have part-time employment,and 14.1%
are unemployed.Nearly 46% reportthat they are
disabled (n ¼ 179) and therefore unable to work,and
85.5% (n ¼ 329) state thatthey suffer from a chronic
condition. Employmentis significantlydifferent
betweendispensarylocation(p < 0.05).Full time
workersare over-representedat VDS and under-
represented at VICS and BCCCS. Unemployed patients
are over-represented at Green Cross.Disabled patients
are over-represented at VICS, Green Cross and BCCCS
and under-represented at VDS.
In terms of education,17.3% had less than a high
schooleducation (n ¼ 67),24% had a high schoolor
equivalenteducation,and 30.9% report having
attended somecollegecourses(n ¼ 120).Just over
24% had a college degree,and 7.2% had a graduate
degree.Education differs significantly by dispensary
location(p < 0.01).Those withouta high school
diplomaand high schoolgraduatesare over-repre-
sented at Green Cross.Patients with some college are
over-represented atVICS and BCCCS and under-
represented at Green Cross.Patients with a college or
graduatedegreeare over-representedat VDS and
VICS and under-representedat Green Cross and
BCCCS.
Income levelsappeared to be significantly lower
than the Canadian average of $28,840cdn from 2009
with 58.2% reporting that they had incomes of less than
$20,000 perannum (n ¼ 219).Twenty-fourpercent
reportearningbetween$20,000 and $39,999,and
17.4% earn $40,000 ormore.This compareswith
63.4% of the Canadian population thatreportearning
$20,000 and over(StatisticsCanada,2012).Income
differs significantlybetweendispensarylocations
(p 4 0.01).Low income patients (less than $20,000)
are over-representedat VICS, Green Cross and
BCCCS and under-represented atVDS. High income
patients(greaterthan $80,000)are over-represented
at VDS and VICS, and under-represented atGreen
Cross.
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Dispensary access and cannabis usage
In termsof patientaccessand use ofdispensaries,
38.8% reportattending a dispensary a couple of days
per week (n ¼ 150),with 15.5% going daily.20.4%
attend once perweek,19.1% one ortwo times per
month,and 5.4% use these services less than once per
month. Additionally, 29.1% state that they access more
than one dispensary.When asked to rank what factors
are mostimportantto them in chosing and using the
dispensary where they filled outthe survey,the staff
topped the list (8.85 on a scale of 1–10, with 1 being of
‘‘non-important’’and 10 being ‘‘extremely impor-
tant’’), followed by the quality of the cannabis products
(8.8),comfortand security (8.59),convenienthours
(8.23), the variety of medicines (7.85), familiarity with
the facility (7.81),and variety ofservicesoffered
(7.40).Loweston the list were closenessto home
(5.82) and knowing the other patients (4.72).
When asked how abouttheirprimary method of
ingestion,48.8% reportedusing joints or blunts
(n ¼ 197),10.4% used apipe, 6.2% used awater
pipe/bong,and 7.9% use oral ingestion (baked goods,
oils, and tinctures). Only 4.7% report using a vaporizer
as their primary method of ingestion. This is more than
twice the rate of vaporizeruse Earleywineand
SmuckerBarnwell(2007)found in a generalsurvey
of cannabis users, which suggests that this sample has a
high commitmentto potentially healthieringestion
techniques compared to cannabis users in the general
population.Eighty eight percent report daily use,with
30.2% reporting that they use cannabis more than four
times per day (n ¼ 122).52.6% reportusing between
six and eightgrams per week (n ¼ 201),with 23.3%
using less than that, and 24.1% using 10 grams or more
per week.
Substance use and substitution
Forty percent of respondents report current alcohol use,
and 49% smoke tobacco.Nearly 20% cite thatthey
have used a drug other than cannabis or prescription
drugs in the past 30 days, with the most common drugs
reported being crack/cocaine (n ¼ 21); heroin (n ¼ 10);
methamphetamine (n ¼ 7);and MDMA (n ¼ 6).Over
52% reportthatthey were raised in an alcoholic or
abusive family environment (n ¼ 195), and 19.6% state
thatthey have been treated foralcoholdependence
(n ¼ 74),with over 5% (n ¼ 22)participating in a
12 step program, and 3.5% (n ¼ 14) in type of another
alcohol recovery program. Additionally, 26.8%
reporting a history of substance abuse (n ¼ 101).
In regards to substitution, a total of 75.5% (n ¼ 305)
of respondents stated thatthey substitute cannabis for
anothersubstance.Over 41% cite that they use
cannabis as a substitute for alcohol(n ¼ 158),36.1%
use cannabisas a substitutefor illicit substances
(n ¼ 137),and 67.8% use cannabis as a substitute for
prescription drugs (n ¼ 259).Reasonscited included
fewerside-effects from cannabis use as compared to
alcohol,illicit or prescriptionsdrugs(39.6%),less
withdrawalfrom cannabis(67.7%), and better
symptom management from cannabis (53.9%).
While those who use cannabis as a substitute for
alcohol are significantlymore likely to be male
(p < 0.05)and to make between $40 and $59,000
annually (p < 0.05),we found no difference in age,
Additionally, they were significantly more likely to be
current drinkers and to report a history of alcohol and
substance abuse (p < 0.05).There was no relationship
between alcoholsubstitution and currentcigarette or
illicit drug use.
Those who report using cannabis as a substitute for
illicit drugs are significantly more likely to be men, to
have a domestic partner, and to be First Nations. They
are significantly lesslikely to be married,and are
significantly youngerthan those who do notreport
substitution for illicit drugs (p < 0.05).Using cannabis
as a substitute for illicitdrugs was also significantly
associated with currentcigarette and illicitdrug use,
and previous alcohol and substance abuse (p < 0.01). It
was not associated with current alcohol use.
When considering the use of cannabis as a substitute
for prescription drugs,the only demographic factor
significantly related was insurance status.Those with-
out additional health insurance were significantly more
likely to substitutecannabisfor prescription drugs
(p < 0.01).Using cannabis as a substitute for prescrip-
tion drugswas not associated with currentalcohol,
cigarette or illicit drug use, or with previous alcohol or
substance abuse.
Amountof cannabis used perweek,frequency of
use and reported change in cannabis use over the past
six months were notrelated to alcoholor illicit drug
substitution.This was also the case forprescription
drugs,exceptfor change in cannabis use;those who
reportsubstitution aresignificantly morelikely to
report an increase in their cannabis use over the past six
months (p < 0.05).
There were no significantassociationsbetween
dispensary or size of the community the dispensary is
located in for alcoholand prescription drugs substitu-
tion and no difference in size of the community and
illicit drug substitution. However, specific dispensaries
were significantly associated with illicit drug substitu-
tion (p < 0.05),with patients from VDS and the Green
Crossbeing more likely to reportsubstitution,and
patients from BCCCS less likely.
DISCUSSION
Self-reportsurveys from over400 medicalcannabis
usersfrom multiple Canadian dispensariesrevealed
thatover 75% of respondents turn to cannabis as an
alternative to some other substance.
In comparing theseresultswith Reiman’s2009
study of cannabis as a substitute for alcohol and other
drugs in patients accessing cannabis atthe Berkeley
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PatientGroup, on averagealmosttwice as many
Canadian patientsreported using a drug otherthan
cannabis or pharmaceuticals in the past 30 days (11%
vs.19.7%).As a result,it is notsurprising thatmore
Canadian patients subsequently reportusing cannabis
as a substitute for illicitsubstances (36.1%) than the
American cohort (26%). Otherwise, the rates of overall
use as well as of self-reported substitution for alcohol
and pharmaceuticaldrugsare very similarin both
studies.
With the recentrise in pharmaceuticalopiate
addiction(Dhalla, Mamdani, & Sivilotti, 2009;
Fischer, Rehm, Goldman, & Popova, 2008;
SAMHSA, 2007), and an associatedincreasein
opiate-relatedmorbidity and mortality (Moore,
Cohen,& Furberg,2007),cannabis may prove to be
a safer substitute to address chronic pain issues.The
three main reasons cited for cannabis-related substitu-
tion in this survey are ‘‘lesswithdrawal’’(67.7%),
‘‘fewerside-effects’’(60.4%),and ‘‘bettersymptom
management’’ suggesting that many patients may have
already identified cannabis as an effective and poten-
tially safer adjunctor alternative to their prescription
drug regimen.
Additionally,since the intravenous use of pharma-
ceuticaland illicit opiates,crack and cocaine,and
crystal meth can all lead to the transmission of serious
conditionslike HIV/AIDS and hep-c,evidence sug-
gesting thatcannabis mightbe an effective substitute
for these highly addictive substances could be part of a
public health-centered harm reduction strategy aimed
at reducing disease transmission and overdoses stem-
ming from injection drug use.This mightbe accom-
plished on a case-by-case basis by having physicians
prescribe cannabis for addiction to individualpatients
where legally possible,or at the population levelby
reducing the penaltiesassociated with cannabis use.
Such policy shifts could have a tremendous potential to
save or redirect scarce public resources away from the
arrestof otherwise law-abiding adults and to reduce
the high rate of morbidity and mortality associated with
the use of injection drugs.
Furthermore,since alcoholhas a far greater social,
health and financialimpacton individuals and com-
munities than allillicit substances combined,public
policies informed by evidence that cannabis might be a
substituteor actualtreatmentfor alcoholaddiction
(Mikuriya,2004;Reiman,2006,2009)could have a
significantimpacton overallrates ofalcoholism,as
well as alcohol-related automobile accidents, violence,
and property crime.
While some studieshave found that a small
percentage of the general population that uses cannabis
may develop a dependence on this substance (Lopez-
Quintero,2011;Perkonigg,2008),a growing body of
research on cannabis-related substitution suggests that
for many patientscannabisis not only an effective
medicine,but also a potential exit drug to problematic
substance use. Given the credible biological, social and
psychological mechanisms behind these results, and the
associated potential to decrease personal suffering and
the personal and social costs associated with addiction,
furtherresearchappearsto be justifiedon both
economicand ethicalgrounds.Clinical trials with
those who have had poor outcomes with conventional
psychologicalor pharmacologicaladdiction therapies
could be a good starting pointto furtherour under-
standing of cannabis-based substitution effect.
LIMITATIONS
Given that this is a preliminary survey study, the results
of this researchcannotbe readily translatedto
population-levelgeneralizations.Patientswho are
extremely ill might not be able to take the time to fill
out the survey. Additionally, medical cannabis patients
mightdiffer substantially from the greater population
of cannabisusers,and thosepatientswho access
dispensariesmay differfrom patientswho produce
cannabis for themselves or who obtain it through other
means.Furthermore,although the survey was anony-
mous,the legalstatusof cannabisand otherillicit
substances might have affected the accuracy of patient
responses. Finally, it is impossible to substantiate self-
reported instances of substitution, so results reflect the
patient’s own understanding substitution vis-a-vis their
substance use history.However,since these results
supportotherstudiesthatsuggestmedicalcannabis
may reduce the use and potential abuse of other drugs,
further investigations should be conducted to examine
the potentialfor cannabisto play a role in the
treatment of addiction,both in the patient and general
population.
Declaration ofinterest:Fundingfor this studywas
provided by the participating dispensaries to coverthe
costof independentpeer-review and a research contract
with Philippe Lucas MA,the Primary Investigator of the
study.Additionally,Mr Lucas is the formerExecutive
Directorof the VancouverIsland Compassion Society
(VICS), one of the four study cites in this project,and
currently has a volunteer position on the VICS Board of
Directors.Co-investigatorsSteffaniMcGowan,Megan
Oleson,Michael Coward,Dori Dempster,and Brian
Thomas were allemployed by participating dispensaries
during the course of this research.
NOTE
1. Correspondencewith Jeet-KeiLung, memberof the CAMCD
Board of Directors,April 2012.
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