CANNABIS & OPIOID SUBSTITUTION: A Q&A with Rielle Capler

Rielle Capler is a PhD cannabis policy researcher at University of British Columbia and the British Columbia Centre on Substance Use. BotaniQ Magazine spoke to Capler about her work and findings in the area of cannabis being used as a substitute for opiates.

Q: What work has been done so far on researching cannabis as a possible opioid substitution? What has your research consisted of in this area?

A: “This is something we’ve been looking at for a long time. It came up anecdotally in the medical cannabis community, where we were hearing about patients weaning off their opiates or stopping their use of opiates and then it was something that as we got into research we started looking at it empirically. We started off doing research on cannabis users, different survey studies, more observational survey studies, and we were asking people about that. We wanted to document that experience more widely and we found that it was a very common phenomenon for opiates as well as other substances that can be potentially problematic, like other pharmaceutical drugs, and alcohol, tobacco in some cases as well. Then some of that research, the more observational work that’s been happening in Canada, and the research I’ve been involved with, but it’s been happening internationally as well, as it just became a very clear story emerging around that…. We’re now kind of moving into clinical studies, more experimental studies. That’s just starting to happen. 

Q: So far, what does the data suggest? Is cannabis a viable option for opiate substitution? Or is the jury still out on that?

A: I would say there definitely is a correlation and an emergent trend that is happening, and people are finding it successful. That’s what’s being reported to us. It’s prevalent. People are consciously using cannabis as a substitute and they’re doing it purposefully and it’s working for them. So that kind of story is definitely emerging from self reports. So in the research context, the next step would be looking at clinical trials to see, how effective is it when compared, for example, to placebos. So that’s kind of the next step…. We’ve also seen more aggregate data in different jurisdictions around usage of different substances that can’t be used problematically reduced in states or jurisdictions that have either medical cannabis, legal access, or recreational. So there’s a lot out there suggesting this is happening and there’s a lot of potential…. Health care providers, they want to see the clinical data. That’s the last step but I think there’s an awareness of this, both among cannabis users and the general population.

Q: What would the societal benefits be if substitution potential was ultimately proven and cannabis substitution programs were ultimately adopted and care providers were embracing them?

A: That’s a good question. It’s a struggle. Problematic use, substance use, addiction, it’s a big struggle. The cost to society of problematic substance use and addiction is very high. So if there’s a tool that can help with that to reduce those harms, that would be great. But we also need to look at… pharmaceutical drugs in the medical context. There’s a lot of side effects to those, health side effects to some of those substances, so a reason why a lot of people use cannabis medically, they’re not finding the pharmaceutical products they’re using to be effective and they’re not liking the side effects so if cannabis can be a substitute in terms of being as or more effective and having less severe side effects, that’s a great benefit. We can look at it in terms of cost savings to the health care system, we can look at it in terms of productivity in society, we can look at in terms of well-being, those are all really important markers. One of the things that occurred to me recently with the news around the gap of prices in the regulated market and the unregulated market, that’s actually something that’s really important to look at, not just in terms of the stated goals of legalization – if the illicit market is not being reduced by legalization. I think of it in terms of this kind of area of substitution or it’s often called instrumental use of cannabis, how does it affect access? It has to be affordable for people to take advantage of these potential benefits. That’s a real concern – we want people to be able to access cannabis for these purposes. They have to be able to afford it and they should be able to access it from a legal source. 

Definitely we’re seeing that in medical cannabis users, who are consciously using cannabis as a medical substitution for other, or an adjunct to the opiates to help them, but I would also say a lot of people who use cannabis medically are still accessing it from the non-medical sources. They have issues accessing it or getting their physicians support and are getting it through that market. So I would say there’s a lot of people who might be using cannabis instead of anxiety medication. I think there are a lot of people who access cannabis who use cannabis for those kinds of symptoms and they’re using it effectively, perhaps more effectively than the pharmaceutical drugs available to them. There are fewer side effects and it has to be affordable to them. When I’m looking at the prices in the legal market, it’s a concern. 

Q: Will it be a long road to get to that point? With the studies done to prove the benefits scientifically?

A: I think there’s a drive for that. But the connection does need to be made. It’s out there, but as we’re seeing in Vancouver for example, in the Downtown Eastside, people are doing that. And there are these different programs that are finding ways to give cannabis out for free, or for very affordable prices. The cannabis substitution project, there are a couple programs down there, but that’s really important, and can’t just be dependent on the good will of the people. That’s a lot to ask. I did an interview the other day about the gap between the prices…. It’s something, when we look at prices, we have to think about the potential benefits of cannabis and who will be able to access them. I don’t think it’s the silver bullet necessarily. There are some concerns that there are other opiate replacement programs that are potentially even more effective, but I think that all the tools should be available. It’s one of the important tools in the harm reduction kit that could be really beneficial. I’ve experienced that, working with the medical dispensaries, I’ve experienced many people weaning off their opiates and a vast improvement in their quality of life. It can happen, but for other people, the opiate replacement programs will be more suitable.

I think it’s important to note that definitely we have to be concerned about the most marginalized people in our society, and we also have to look at everyone as well, because at certain prices the average person wouldn’t be able to afford cannabis. Not in the amount they might need if it’s being used instrumentally in that way. So it’s imperative to get those prices down. And in the meantime to have some kind of understanding that the black market, the unregulated market, is still serving a purpose. 

It’s been a long road. But it’s becoming shorter because of legalization. Anecdotally, we were hearing about this 20 years ago, and more. But all we could do until legalization was the observational studies, surveys, and interviews as well. We had to document it and look at aggregates. That was all we had. So legalization really has been incredible in terms of opening up the door for clinical research, in terms of having access to legal product and also in terms of having some funding. It was impossible before. It was taking it from the ground level all the way to the top. It’s been a long road but it’s definitely in view now. It’s one of the most exciting parts of legalization.

This interview has been condensed for length.

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