As a growing number of Democratic presidential contenders are voicing support for harm reduction programs such as supervised injection facilities (SIFs), a recent study shows that these candidates are on the right track if they’re really interested in helping save the lives of people who use currently illegal drugs.
Researchers in British Columbia, Canada, found that people “who reported using supervised injection facilities on an at least weekly basis had a reduced risk of dying compared to those who reported less than weekly or no use of this health service.”
Previous studies have shown that safe injection sites help reduce overdose deaths. However, there are only approximately 140 legally operating sites in the world, including in Canada, Australia and Europe. To date, no SIFs have legal approval to operate in the U.S., though some cities are exploring allowing such facilities to open.
To understand whether SIFs affect overall mortality, researchers used data from two prospective cohort studies of people who inject drugs (PWID) in Vancouver, Canada. Every six months between December 2006 and June 2017, participants responded to a questionnaire asking about sociodemographic information, drug use, use of health interventions such as SIFs and more. They were also asked to provide blood samples for medical testing or monitoring.
Ultimately, the total sample included 811 participants. More than half (432) reported frequent (that is, at least weekly) SIF use at baseline. Over the span of the study period, 112 participants died, corresponding to a crude mortality rate of 22.7 deaths per 1,000 person-years. The leading causes of deaths were non-accidental (which included neoplasms and circulatory disease), ill-defined or unknown, overdose and HIV-related.
After adjusting for several factors, including age, sex, HIV seropositivity, public injection and more, researchers found that “frequent SIF use remained significantly associated with decreased risk of all-cause mortality.”
“Existing modeling and simulation studies indicate that SIFs avert numerous overdose deaths per year,” the study, which was published in the journal PLOS Medicine in late November, states. “Moreover, past research relying on aggregate data has demonstrated the role of SIFs in reducing local population-based rates of fatal overdose. However, we believe that ours is the first study to identify an individual-level association between frequent SIF use and decreased risk of all-cause mortality among a community-recruited cohort of PWID.”
Although researchers did not investigate why there was an association between frequent SIF use and a lower risk of all-cause mortality, they do offer some potential explanations based on existing literature. Studies have shown that supervised consumptions sites are associated with safer syringe use, including a decline in sharing, reusing, outdoor injecting and hurried injecting. Additionally, these facilities are equipped to handle medical emergencies, such as overdose, and are staffed with people trained in addiction treatment.
“Together with the findings of previous research,” the authors write, “our findings underscore the need for continued efforts to enhance access to SIFs as a strategy to reduce mortality among PWID. In particular, given that SIFs have limited geographic coverage and that PWID have been found to often encounter long wait times in accessing SIF services in this setting, the broader expansion of SIFs may serve to improve service accessibility and thereby reduce the potential for mortality and other harms among this population.”
At a time when evidence-based interventions are urgently needed to address the disproportionately high burden of preventable deaths and suffering experienced by people who use drugs, efforts to scale up access to supervised injection facilities should be a public health priority.
— Mary Clare Kennedy, PhD (@MCKennedy_) November 27, 2019
Lead author Mary Clare Kennedy summarized her study results online, tweeting in part: “Our findings add to the large body of scientific evidence demonstrating the critical role of supervised injection facilities in saving lives, reducing harm & promoting health among people who inject drugs.”
“At a time when evidence-based interventions are urgently needed to address the disproportionately high burden of preventable deaths and suffering experienced by people who use drugs, efforts to scale up access to supervised injection facilities should be a public health priority.”
On the presidential campaign trail, entrepreneur Andrew Yang, South Bend, Indiana Mayor Pete Buttigieg, former Housing and Urban Development Secretary Julián Castro, Sen. Elizabeth Warren (D-MA) and Sen. Bernie Sanders (I-VT) have all voiced support for safe consumption sites.
Photo by Jair Lázaro on Unsplash
Feds Funding Research On How Marijuana Consumers Are Impacted By Coronavirus
A top federal agency is asking researchers to submit grant applications to study how people who consume drugs—particularly those who smoke or vape marijuana or tobacco—are uniquely impacted by a coronavirus infection.
In a notice from the National Institute on Drug Abuse (NIDA) that was published last month, the agency said the rapid spread of the pandemic makes it imperative that researchers identify potential medical complications for people who contract the virus and use substances that could compromise their respiratory system or other health functions.
Two grants have been made available to scientists who are able to investigate these issues.
“As people across the U.S. and the rest of the world prepare for what could be a pandemic of the 2019 novel coronavirus, or COVID-19, the research community should be alert to the possibility that it could affect some populations with substance use disorders or HIV particularly hard,” NIDA said. “Because it attacks the lungs, COVID-19 could be an especially serious threat to those with histories of smoking tobacco or marijuana or of vaping.”
“People who use opioids or methamphetamine may also be vulnerable due to those drugs’ effects on respiratory and pulmonary health and potential effects on immune mechanisms. Likewise, those with HIV may be affected if their immune function is compromised,” the notice continues. “Additional social and environmental factors associated with drug use may worsen the transmission and treatment of COVID-19, especially among individuals who experience homelessness or incarceration, which is more common among those with a substance use disorder.”
NIDA listed a series of research objectives it hopes to expedite, including whether substance use, “especially smoking tobacco or marijuana, vaping, opioids and other drug use,” could be a risk factor in the onset or progression of the coronavirus.
It also wants to generally “understand the respiratory effects” of such behaviors, “in particular those with nicotine, marijuana, opioid, and methamphetamine use disorders.”
The notice also states that the agency is interested in learning about the impact of a coronavirus infection among pain patients who use opioids and those with opioid misuse disorders. NIDA said studies investigating how the virus “influences the outcomes for naloxone interventions for overdose reversal” are also of interest.
The agency will be accepting applications for the grants on a rolling basis through March 31, 2021.
Federal agencies have made a series of requests for scientific submissions on cannabis-related topics in recent months. For example, the Agency for Healthcare Research and Quality put out a call for studies on the impact of marijuana on pain and migraines in January.
Youth Marijuana Treatment Admissions Fell After Legalization, Study Finds
Does legalizing marijuana for adults lead to a tidal wave of teens going to treatment? Not according to a new study out of Temple University, where researchers in fact found decreases in youth admission rates for problem cannabis use in two legal states.
The findings, published this month in the journal Drug and Alcohol Dependence, run counter to speculation from legalization opponents, law enforcement and some public health experts, who have warned that relaxing cannabis laws could lead to an explosion in cannabis use disorders among children. If that’s happening, the study found, treatment admissions data so far show no sign of it.
Examining data from publicly funded substance use treatment facilities, researchers from Temple’s geography and urban studies department, found that youth treatment admissions rates for cannabis use disorder fell sharply between 2008 and 2017, nationally as well as in Colorado and Washington State, which both passed legalization laws in 2012.
“Our results indicate that [recreational marijuana legalization] in Colorado and Washington was not associated with an increase in treatment admissions,” the study concluded. “Rather, we observe a substantial decline in admissions rates across US states, with evidence suggesting a greater decline in Colorado/Washington following RML as compared to non-RML states, though this difference was not significant.”
Co-author Jeremy Mennis, a Temple professor, told Marijuana Moment that the “national decline is pretty dramatic,” noting that on average, youth admissions rates for marijuana fell by nearly half.
“It declined more in Colorado and Washington, but the difference between them and other states was not statistically significant,” he said.
In other words, at least so far, legalization doesn’t seem to have made a particularly big impact on youth admissions rates one way or the other.
“Adolescent treatment admissions for marijuana use did not increase in Colorado and Washington following [recreational marijuana legalization].”
“The admissions rate is initially higher in Colorado/Washington at the beginning of the study period,” Mennis and co-author Gerald Stahler wrote, “but declines more rapidly following [legalization] as compared to the other states.”
As the study notes, if legalizing cannabis for adults were to increase the prevalence of cannabis use disorder among youth, “one potential consequence would be an increased need for treatment.” But that increased need hasn’t been reflected in actual admissions rates.
Still, the researchers are quick to caution that a drop in treatment admissions doesn’t necessarily mean a decrease in problem marijuana use.
“We’re not sure whether cannabis use disorder is declining or just treatment admissions are declining” for some other reason, Mennis said.
Youth cannabis consumption in the U.S. “has not substantially increased over the last 10 years,” he said, but it’s not drastically fallen, either. Yet since about 2011, treatment admissions have steadily declined.
Why the drop in admissions rates? “I don’t know why,” Mennis acknowledged. “This is speculative on my part.”
One possibility is that changing attitudes toward the potential dangers of marijuana have shifted in recent years, making individuals and their loved ones less likely to seek treatment.
“The perception that using marijuana is harmful has declined across the U.S. among youth and adults,” Mennis said, “and this may affect how people view whether their marijuana use is problematic or requires treatment.”
If fewer parents see cannabis as a harmful drug, for example, “they’re probably a lot less likely to see the use of marijuana among their kids as warranting treatment,” he said. “That’s a possibility.”
Reduced stigma around cannabis generally could also be playing a role, he said, with parents perhaps less likely to refer their kids to treatment for simply experimenting with the drug absent other problems connected to such use.
Perhaps the worst-case scenario, the paper says, is that the need for treatment still exists but somehow isn’t being met:
“If [cannabis use disorder] remained stable following [recreational marijuana legalization], or increased, as recent research indicates, the dramatic decline in adolescent treatment admissions we observe in states enacting [recreational marijuana legalization] would suggest an increase in unmet need for treatment, i.e. it may be the case that admissions rates are falling because an increasing proportion of adolescents with CUD are not entering treatment.”
“Cannabis use disorder is a thing, and I think a lot of people are resistant to the idea that it can be a thing. The question is whether cannabis use disorder is actually decreasing,” Mennis said. “If cannabis use is staying the same, then there’s a bigger and bigger gap.”
Studies on cannabis use disorder have arrived at mixed conclusions about whether it’s becoming more or less common as legalization spreads to more states. A study published last year found that, contrary to the expectations of some health experts, the prevalence of cannabis use disorder among frequent cannabis users has actually decreased in recent decades.
Cannabis use disorder “decreased significantly across all ages reporting daily/almost daily cannabis use between 2002-2016,” that study found. “Cannabis dependence prevalence decreased for adolescents and young adults and was stable only among adults ages 26+ reporting daily/almost daily cannabis use.”
Photo courtesy of Martin Alonso
Federal Agency Wants Help Developing A Standard THC Dose For Marijuana Products
A top federal health agency is requesting input on a proposal to establish a standardized dose of THC in marijuana products to ensure consistency among studies into the potential therapeutic benefits and risks of cannabis.
In a notice published by the National Institute on Drug Abuse (NIDA) on Monday, the agency said that little is known about the impact of varying THC potency, and creating a standard unit could help resolve that issue. That said, the notice acknowledges that marijuana contains other compounds that could complicate any standardization, in addition to problems arising from differing methods of consumption.
Even so, “such a unit is critical for conducting rigorous cannabis research,” NIDA said.
“Recognizing that a perfect measure may not be attainable at the current time, NIDA still believes that a standard dose would improve measures of outcomes in relation to exposure; and thus, could inform policy and public health strategies around cannabis use,” the notice states, adding that the agency is looking into a five milligram THC dose as the standardized unit.
Request for Information (RFI): Inviting Comments on the Establishment and Implementation of a Standard Unit Dose of Delta-9-tetrahydrocannabinol (THC) for Cannabis Research https://t.co/RkSzihPpbP
— NIH Funding (@NIHFunding) March 23, 2020
NIDA Director Nora Volkow discussed the importance of establishing such a unit in commentary published in the journal Addiction last month.
Citing research that calls for a five milligram THC standard, Volkow said she agreed with the study’s conclusion despite complicating factors. Those factors include potential issues related to the effect of having cannabis products with the same THC level but different concentrations of other cannabinoids such as CBD.
Also, varying routes of administration could present problems in ensuring research consistency. It’s unclear how the effects of a five milligram THC unit would differ between marijuana products consumed via smoking, vaping, edibles or topicals.
The notice also calls for information about labeling requirements for cannabis products. But while that might aid in observational or epidemiological studies, a federal standard for labels wouldn’t be achievable as long as marijuana remains a prohibited substance. The Trump administration’s secretary of health and human services talked about this problem as it applies to warning labels last year.
The complexities in research beyond having a standardized measure of THC “hardly negate the value” of setting one, Volkow said in her commentary. “In fact, having and using such a standard is a prerequisite for comparing the effects of various cannabis products on THC bioavailability, pharmacokinetics and pharmacological effects, which is knowledge fundamental to studies pertaining to medical use of cannabis.”
“Although cannabis remains an illicit substance in the United States, the expanded legalization by states requires us to develop the knowledge base that can help states develop policies to minimize risk from cannabis exposures, such as limits on the THC content of cannabis products,” she said.
Due to the lack of standardization, she said that studies often show conflicting results when it comes to questions about how cannabis impacts brain development and mental health conditions, for example. There’s also a lack of consistency in research comparing the effects of high THC and low THC marijuana.
In the study Volkow references, the authors said they examined “experimental and ecological data, public health considerations and existing policy” to determine that five milligrams of THC should be the standard unit.
The director said in her commentary that in spite of the “multiple caveats and complexities, the use of a standard unit dose of THC in research is an important step for improving our ability to understand the effects of cannabis in the population.”
NIDA’s notice calls for e-mailed submissions from “the scientific research community and any other interested parties” by May 1.
Volkow has been vocal about the importance of streamlining and improving research into cannabis, and she’s laid partial blame for the the lack of studies on marijuana’s restrictive federal classification.
While it remains to be seen when that fundamental impediment will be resolved, the Drug Enforcement Administration did announce last week that it is proposing a rule that would enable it to expand the number of authorized cannabis manufacturers for research purposes.
Photo courtesy of Martin Alonso.