Cannabis as an “adjunctive treatment” for MAT patients?

December 27, 2020

Those harm reduction initiatives are great. I would say ‘keep doing that’. But also give people the opportunity to get well because that mantra of ‘keep them alive, keep them alive’ isn’t good enough. As a person in long-term recovery, I see it as a lack of ambition. It’s disrespectful to assume I am not worthy of healing.

Annemarie Ward

I shared a larger quote the other day that included this and it got some pushback from people who read it as dismissive of harm reduction or an expression of one-way-ism. I explained that I don’t read it that way at all.

At any rate, I read a press release about a recently published study and Annemarie’s words about “lack of ambition” came to mind.

The study focused on opioid agonist patients in Vancouver, BC. Here’s what the press release reports:

There were 819 participants in the study.
53% tested positive for fentanyl despite being on opioid agonist treatments (OAT).
Participants who tested positive for cannabis were 10% less likely to test positive for fentanyl.

The paper adds the following:

All were receiving opioid agonist treatments in a community setting.
More than 80% were receiving methadone
53.6% tested positive for cocaine
44.7% tested positive for methamphetamine

There are a few things that are a little confusing in the paper, but I believe they report:

66% tested positive for cannabis. ¹
People who tested positive for cannabis were more likely to test positive for benzos. ²

Those are the findings.

As with most things, there’s more than one way to understand the findings. Some might question the efficacy of the treatment, others might wonder if there are any psycho-social services provided, and others might wonder about the dosing. I think most people would view these as disappointing findings, particularly given BC’s status as a frequently cited North American leader on drug policy.

These researchers bring a different set of assumptions and reach a different set of conclusions.

these patients are “supplementing their treatment” with street drugs
reduced fentanyl use means reduced risk of OD
the 10% lower rates of positive fentanyl tests among patients testing positive for cannabis is understood as “stabilizing”
this underscores the need to better understand “the therapeutic potential of cannabinoids as adjunctive treatment”
daily cannabis users were 21% more likely to be retained at 6 months, which is understood as “a beneficial link between high-intensity cannabis use and retention in treatment”
this is in the context of a growing evidence-base “suggesting cannabis could have a stabilizing impact”
“cannabis might have a role in addressing the overdose crisis”

What the study and press release don’t tell us:

rates of benzo use among patients and, more specifically, those who test positive for cannabis
rates of use for opioids other than fentanyl
what are the retention rates in the programs these patients received services from?
other kinds of treatment patients may be receiving
patient satisfaction with their treatment, progress, and quality of life
what other options are available to these patients

I have two reactions to this.

First, I can’t help but wonder if the researchers would find these outcomes attractive or promising for themselves or a loved one.

Stigma gets a lot of attention these days. We usually associate stigma with judgmental or punitive responses to to addiction. I believe that low expectations are a too frequently ignored manifestation of stigma. Personally, I believe these outcomes could only be considered good in the context of seeing these patients as hopeless or as an “other.”

Second, we hear a lot of calls to follow the science, for evidence-based treatment, and OAT as the gold standard of care, often to the point of delegitimizing other models.

This study and press release highlight the importance of asking “evidence-based for what?” Does the evidence-base address your goals and hopes for yourself of your loved one? When experts communicate the evidence-base to you, what hidden assumptions are embedded? ⁴

Continued evaluation of treatments is extremely important. We do not have any silver bullet treatments and need to accurately communicate the strengths weaknesses of each option, and explore how they align with their goals. Yes, OAT dramatically reduces OD, but retention rates are not great and the evidence-base does not speak to the goals of many patients. Yes, PHPs have outstanding outcomes, but many PHP elements are not available to most patients and coercion undoubtedly plays a role in the success of those programs.

It’s an unfortunate truth that any patient or family member should be very skeptical of anything they hear from treatment providers, advocates, researchers, and journalists. This isn’t to say everyone is untrustworthy or dishonest, but too many of us are focused on a relatively narrow set of concerns. A friend compared understanding addiction, recovery, & treatment to an 8 sided die and added that most practitioners, advocates, researchers, and journalists are focused on only one side of the die.

See table 1, row 1. It looks like 66%, but the fact that the Ns for columns 2 and 3 don’t equal the N for column 1 is throwing me.
It says “at baseline”, which doesn’t make sense to me, because this is just an observation of OAT patients over a period of time.
This statement referred to a study on OAT improvements over a 10 year period with the implementation of a cascade of care model. They defined retention as ≥ two observations in a given calendar year at least three months apart where the participant reported being enrolled on OAT. Retention rates improved from 29.1% to 35.5%. They defined stabilization as no self-reported overdoses, no binge drug use and no fair/poor self-reported health due to drug use among participants retained in OAT in the calendar year. Stabilization rates improved from 10.1% to 17.1%.
This is not specific to OAT. These questions should be applied to all information about treatment and outcomes, whether it’s residential, outpatient, OAT, or whatever.

Thanks to Brian Coon for his comments on this post.