O Canna(da)!

As the second country in the world to legalize recreational cannabis, all eyes are on Canada – and its researchers are likely to find themselves in a more prominent position on the world stage. Are they ready for it? And will each business and field have equal opportunity to benefit? Four months in, we talk to three experts from the worlds of research, education and consultancy to find out what they think about Canada’s green rush – and to explore the impact it will have on science, business and human health.

Read the second part here:

Friend, Not Foe, with Adolfo Gonzales (CannaReps)

The Cannabis Conduit, with Barinder Rasode (Grow Tech Labs)

 

Potential Versus Panacea

With MJ Milloy

It’s an exciting time in Canada. Last week, I went to the first store to sell legal cannabis in the city of Vancouver. What struck me was how busy it was; many of the people buying products were saying how they had never used cannabis before but, now that it was legal, they wanted to try it ­in the hope that it would address some of their health concerns.

The gates are open

Cannabis science is going through a bit of a renaissance. In Canada, something like 90 percent of the population live within 20 miles of the US border and much of our society is constructed in relation to the USA. But now we have a fully legal framework and the support of the government, we are able to do research that cannot be accomplished over the border. And though it is always challenging to get enough money for science (no matter the country), we are fortunate that the federal government, as well as the cannabis producers, are supportive of funding research.

These are all tremendous advantages – and, post-legalization, I hope we can turn these advantages into scientific evidence. Among my colleagues, there are many dedicated scientists working in various fields, from arthritis to mental health to multiple sclerosis, and now the gates are wide open, I’m hopeful that we can begin to answer questions around the role cannabis might play in health and wellbeing. In the future, it’d be great to see Canadian researchers taking a bigger role on the world stage.

I am the inaugural professor of cannabis science at UBC – the first in the province. Canopy Growth, a licensed producer of cannabis, the government of British Columbia and my university all came together, decided this was a good idea and hired me. For any researcher to get this recognition – and, more importantly, support – for research is something that I’m tremendously grateful for. I’m a relative newcomer to the field, but I’m lucky that there are Canadian researchers who established programs of research when cannabis was still illegal, despite the challenges. It’s a very good time to be in research in Canada – it is marked by a real diversity of viewpoints; people are involved from a lot of different areas; social work, law, government policy…

THC and HIV

With the privilege of my position comes responsibility, of course. I started my academic training as an epidemiologist looking into illicit drug use, especially in the context of HIV infection – unfortunately, we have a lot of people here in Vancouver who have acquired HIV through drug use. As a country we have lost thousands of fellow citizens to drug overdoses in the last couple of years – a completely preventable form of death. To try and address this, we need to generate useful scientific evidence and put new tools in the hands of doctors, nurses, paramedics, as well as people who use drugs and their family members. Addressing that toll of death is what motivates all of us here at the BCCSU.

Back in 2005, I was aware that many people living with HIV used cannabis, but it was not a research priority for me. Then I saw a study by Patricia Molina and colleagues in New Orleans showing that monkeys exposed to THC had lower amounts of simian immunodeficiency virus in their blood, compared with monkeys that did not receive THC. I led a study in the mid-2010s to see whether a similar effect can be seen in humans. We found that in the year after people acquired the infection (before they began treatment with antiretroviral drugs), those who were using cannabis at least once a day had significantly lower levels of the virus in their blood than those who were not.

We know that HIV is primarily a disease of inflammation, and CBD in particular has been shown to be anti-inflammatory. The hypothesis is that by lowering the amount on inflammation in the body during that acquisition period there is less chance for the virus to replicate, but that is still only a hypothesis. That’s the closest I’ve come to a “Eureka!” moment as a scientist, and it really opened my eyes to the possible impact of cannabis in the populations we study.

Our findings should certainly not be taken as any indication that you can manage your HIV infection with cannabis, something I point out whenever I present this work. It needs to be said – especially here in Vancouver when people are always looking for “natural” ways of dealing with their health – if you’re living with HIV, the best thing you can do is get on treatment and stay on treatment.

People on treatment have much slower disease progression, and cannot pass it onto their sexual partners or other partners. That’s positive – but they still experience co-morbidities as a result of chronic inflammatory process, such as depression, anxiety, and HIV-associated pain. This, and improving quality of life, is where I think cannabis might be useful.

The opioid crisis

A lot of my more recent research with cannabis has been examining its impact in the context of addiction, especially addiction to drugs. We have an overdose crisis in the United States and Canada, which is largely the result of people addicted to opioids like heroin being exposed to new and more powerful opioids, such as fentanyl. We are interested in whether cannabis might benefit these people and lower the risk of overdose.

For the last 20 years, we have been running cohort studies involving 3,000–4,000 people who use drugs. They are marginalized; many are homeless, living in poverty, living under stigma and – if a heroin or a cocaine user – run the risk of being arrested and incarcerated. These are all barriers to health, and unfortunately they are the ones who are suffering the most from the overdose crisis and with very high death rates.

The need really is quite clear: to develop new treatments, and to develop new strategies for them to be able to improve and protect their health. We have over 20,000 interviews with these individuals, spanning 20 years, and we have been looking at that data to explore the possible benefits of cannabis. For example, we have found that, if people who are starting treatment for opioid use disorder are also using cannabis at least once a day, they were 21 percent more likely to still be in treatment six months later. That’s a positive – we know that keeping people in treatment, getting them on methadone or buprenorphine is the best way to ensure that they don’t suffer the harms of opioid use disorder, such as overdose or HIV acquisition.

We’ve also shown that people using cannabis every day are about 30 percent less likely to start injecting drugs – which in turn lowers someone’s risk of overdose/getting HIV. It looks as if people are using cannabis to try and control or reduce the harms of other forms of drug use, which is very encouraging. We are planning some clinical trials (thanks to support from Canopy Growth) and hoping we can translate these findings into experimental studies.

Our pilot trial is to see if we could pair existing treatments for opioid use disorder, like buprenorphine, with cannabis – and whether that promotes retention in treatment, improves their quality of life or reduces pain or anxiety. As you may know, there is a lot of preliminary evidence that cannabis could be useful; and a now famous study shows that those states in the US with medical cannabis systems have about 25 percent lower rates of opioid-related death. We are hoping to fill in some of the gaps to see if that is borne out at the community level. I hope that will be useful for other communities grappling with drug overdose.

It is challenging to get a clinical trial like that up and running – and because of decades of cannabis prohibition there is a backlog of research – but one of the benefits of legalization is that it is much easier to do this kind of work. My friend and colleague, Mark Ware at McGill University was the first in Canada to do a clinical trial using cannabis and it took him over ten years to get all the licensing settled.

We are also doing a scientific evaluation of a community group here in Vancouver that is handing out cannabis for free to people who are at risk of overdose in the hopes of lowering the risks. A year from now, I hope that we will be able to share what we have learned in terms of the benefits and possible risks of that intervention.

From a scientific point of view, we need to ask ourselves what might be the best cannabis to use for these trials, in terms of its form, of its relative ration of cannabinoids and so on. From our preliminary work it seems that some people really benefit from high doses of CBD-based pill formulations, whereas some people want the immediate effect of smoking.

There is still much for us to learn in terms of conducting trials, licensing, regulations and so on – largely because a lot of it is still being drafted and determined. It is going to be a challenge, but we are certainly excited by it!

Delivering the message

I’m not one of those people who think cannabis is a panacea, and I certainly don’t think my job is to prove that cannabis is useful. I’m lucky to be working on the medical end, where the possible benefits of cannabis are exciting. But people should be mindful – as with any psychoactive substance. With any intervention – be it cannabis, another molecule, or a social program – you have to balance the risks against the benefits. Cannabis is no different, even in the medical sphere. I do think that is has tremendous potential, however, and I think that for the last century or so it has been unfairly maligned.

People (including scientists) have focused too much on the possible risks of cannabis, and not enough on the possible benefits. Eminent English scientist David Nott has shown that if you compare cannabis at a public health or an individual health level to other substances, including legal substances, it’s quite clear that the risks of cannabis pale in comparison to alcohol or tobacco or other drugs.

Anyone working in the field is likely concerned about the possible negative consequences of legalization, but, at the same time, I believe that people should not be put in cages for using drugs – any drugs. I think that instead of using a public security approach to issues, we should be using a public health approach  – and appears to be what the Canadian government has tried to do with cannabis – to regulate it like any other substance.

I never thought I would end up here, studying cannabis. I’ve had my mind changed not only because of the work I’ve done, but also through talking to the participants in my studies and others who are using cannabis therapeutically, including family members here in Vancouver. For many people, it makes a lot of difference in their lives and I am lucky to be able to see that. The impetus for my work is to really see whether those benefits can be borne out in a scientific study – and I’m delighted to be playing a part in the process.