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Published in final edited form as: Addict Behav. 2023 Sep 22;148:107867. doi: 10.1016/j.addbeh.2023.107867

CANNABIS USE TO MANAGE STIMULANT CRAVINGS AMONG PEOPLE WHO USE UNREGULATED DRUGS

Hudson Reddon a,b, Maria Eugenia Socias a,b, Kora DeBeck a,c, Kanna Hayashi a,d, Zach Walsh a,e, M-J Milloy a,b
PMCID: PMC10896268  NIHMSID: NIHMS1969049  PMID: 37748225

Abstract

Background

We sought to analyze the association between cannabis use to manage stimulant cravings and self-reported changes in stimulant use among structurally marginalized people who use unregulated drugs (PWUD).

Methods

The data for this secondary analysis was collected from a cross-sectional questionnaire administered to people who concurrently use cannabis and unregulated stimulants in Vancouver, Canada. We used logistic regression models to analyze the association between cannabis use to manage stimulant cravings and self-reported changes in the frequency of stimulant use.

Results

In total, 297 individuals were included in the present study. Cannabis use to manage stimulant cravings was reported by 134 (45.1 %) participants and 104 (77.6 %) of these participants reported decreasing their stimulant use during periods of cannabis use. In the multivariable logistic regression analysis, cannabis use to manage stimulant cravings (adjusted Odds Ratio [aOR] = 0.24, 95 % confidence interval [CI]: 0.10, 0.56) was significantly associated with self-reported reductions in stimulant use. In the sub-analyses, cannabis use to manage stimulant cravings was significantly associated with reduced stimulant use among people who used crystal methamphetamine daily (aOR = 0.08, 95 % CI: 0.02–0.37) and was not significantly associated with reduced stimulant use among people who used crack/cocaine daily (aOR = 0.33, 95 % CI: 0.04–2.86).

Conclusions

These findings indicate that cannabis use to manage stimulant cravings is a common harm reduction strategy and suggest that this may be an effective strategy to reduce stimulant use among some PWUD.

Keywords: Cannabis, Stimulants, Substitution, People who use drugs, Cravings

1. INTRODUCTION

The expanding legalization and regulation of recreational cannabis use has been accompanied by ongoing scientific debate surrounding the impact of cannabis use on the use of other higher risk substances such as opioids and stimulants (Wilson et al., 2022, Lucas et al., 2019). Among people who use unregulated drugs (PWUD), cannabis substitution for stimulants has been identified as a commonly reported method of harm reduction (Mok et al., 2021), and cannabis use was associated with reductions in stimulant use behaviours among youth and adults who use drugs (Socias et al., 2017, Reddon et al., 2018). Given the ongoing drug toxicity crisis, and evidence that fentanyl contamination has been identified in more than one in ten unregulated stimulant samples, further investigation of cannabis use as a substitute for stimulants may have important public health and harm reduction applications among PWUD at a heightened risk of overdose and other drug-related harms (Knill et al., 2022, Fischer et al., 2015). However, the motives for cannabis use (e.g., harm reduction/substitution) that may be linked to changes in stimulant use have not been systematically examined and other studies have identified increased harms associated with cannabis use among people who use unregulated stimulants (Wilson et al., 2022, Daldegan-Bueno et al., 2021). Based on this evidence gap, we sought to investigate the prevalence of self-reported use of cannabis to manage stimulant cravings among PWUD, and the extent to which reporting cannabis use to manage craving was associated with self-assessed changes in the frequency of unregulated stimulant use. Given the increasing prevalence of crystal methamphetamine use in our study setting (Bach et al., 2020), we also conducted sub-analyses of the effect of cannabis use to manage stimulant cravings among people who use crack/cocaine and people who use crystal methamphetamine.

2. MATERIALS AND METHODS

The data for this study were collected from three prospective cohorts of PWUD in Vancouver, Canada: the At-Risk Youth Study (ARYS), the Vancouver Injection Drug Users Study (VIDUS), and the AIDS Care Cohort to Evaluate Exposure to Survival Services (ACCESS), which have been previously described (Reddon et al., 2018, Lake et al., 2020). ARYS includes street-involved youth (defined as being without stable housing or having accessed street-based youth services in the past 6 months) aged 14 to 26 years; VIDUS includes adults who report injection drug use in the month preceding enrollment and are HIV seronegative; ACCESS includes adults living with HIV. Participants from all three cohorts report using unregulated drugs other than or in addition to cannabis in the previous month, residence in the Greater Vancouver Regional District, and provided written informed consent.

Between November 2019 and July 2021, individuals from these three cohorts who reported cannabis use in the last six months were invited to complete a supplementary cannabis questionnaire that queried frequency of cannabis use, route of administration, cannabinoid ratio, motivations for use and effects of cannabis use on other substance use (e.g., substitution vs. complimentary effects). Participants were remunerated CA $40 for their time to complete the primary cohort questionnaire and an additional CA $40 to complete the supplementary cannabis questionnaire. The University of British Columbia/Providence Healthcare research ethics board approved these studies.

The analytical sample for the present study included all participants who were aged 18 years or older, completed the supplementary cannabis questionnaire and reported stimulant use in the past six months. The outcome of interest was self-reported change in stimulant use during periods of cannabis use. This variable was operationalized by classifying participants as “1″ if they responded “Somewhat agree” or “Strongly agree” to the item, “When I use cannabis, I don’t need to use as much of the stimulants that I am taking.” Participants were coded as “0” if they responded “Strongly disagree,” “Somewhat disagree” or “Neither agree nor disagree” to this item. The primary explanatory variable of interest was self-report of using cannabis to manage stimulant cravings based on the item, “In the last 6 months, have you used cannabis to help reduce cravings for stimulants?” We also included secondary covariates in the analysis that were hypothesized as potential confounders of the association between cannabis use and stimulant use based on their association with cannabis use patterns or stimulant in previous empirical studies of PWUD (Mok et al., 2021, Socias et al., 2017, Lake et al., 2020, Reddon et al., 2021, Reddon et al., 2023). These variables included self-reported sex at birth (male vs. female); age (per five years older); race/ethnicity (white vs. Black, Indigenous and people of colour [BIPOC]); licit employment (i.e., having a regular, temporary, or self-employed work vs. none); homelessness (defined as living on the street with no fixed address at any time in the 6-month period preceding the follow-up interview); cannabis use frequency (≥daily vs. < daily); cannabinoid ratio (high-THC vs. high-CBD). Variable definitions are consistent with previous studies and refer to the six-month period prior to data collection, except for race/ethnicity (Mok et al., 2021, Socias et al., 2017, Lake et al., 2020, Reddon et al., 2021, Reddon et al., 2023).

We used logistic regression models to estimate the unadjusted and adjusted Odds Ratios (OR) and 95 % confidence intervals (CI) for variables associated with self-reported reductions in stimulant use. The adjusted models included all covariates. We also conducted sub-analyses of the association between cannabis use to manage stimulant cravings and self-assessed changes in stimulant use separately among people use who crack/cocaine and crystal methamphetamine daily, as well as among people above and below the median age of 44 years. These adjusted models also included all covariates. All statistical analyses were performed using SPSS version 28 (IBM Corporation, New York, USA) and all tests of significance were two-sided with a significance threshold of p < 0.05.

3. RESULTS

A total of 297 participants (ACCESS: n = 92, 31.0 %; VIDUS: n = 96, 32.3 %; ARYS: n = 109, 36.7 %) reported cannabis and stimulant use in the last six months and were included in the present analysis. The response rate for the supplementary cannabis questionnaire was > 95 % from each of the three parent cohorts. The median age of the participants was 44.3 years (interquartile range [IQR]: 30.2–54.9), 93 (31.3 %) were female, 118 (39.7 %) reported BIPOC race and ethnicity and 145 (48.8 %) reported daily cannabis use. Self-reported use of cannabis to manage stimulant cravings was reported by 134 (45.1 %) participants and 104 (77.6 %) of these participants reported decreasing their stimulant use during periods of cannabis use (Supplementary Table 1). Other common harm reduction or therapeutic motives for cannabis use included to manage cravings for unregulated opioids (n = 76, 25.6 %) and managing pain (n = 53, 17.8 %). Intoxication was the most commonly reported recreational motive for use (n = 54, 18.2 %). Daily cannabis use was reported by 145 (48.8 %) participants and the most common routes of administration were smoking (n = 289, 97.3 %), edibles (n = 130, 43.8 %) and concentrates (n = 65, 21.9 %). The most common sources of cannabis access were dispensaries in the Downtown Eastside (DTES) neighbourhood of Vancouver (n = 111, 37.4 %), friends and family (n = 90, 30.3 %) and dispensaries outside the DTES (n = 33, 11.1 %). The frequency of daily cannabis use (P = 0.129), daily stimulant use (P = 0.227), using cannabis to manage stimulant cravings (P = 0.797) and decreases in stimulant use during periods of cannabis use (P = 0.373) did not differ significantly among participants from the three parent cohorts (ACCESS, VIDUS, ARYS).

In the adjusted logistic regression analysis, cannabis use to manage stimulant cravings (adjusted OR [aOR] = 0.24, 95 % CI: 0.10–0.56) and daily cannabis use (aOR = 0.26, 95 % CI: 0.11–0.62) were significantly associated with reduced stimulant use during periods of cannabis use (Table 1). In the first sub-analyses, cannabis use to manage stimulant cravings was significantly associated with reduced stimulant use among people who used crystal methamphetamine daily (aOR = 0.08, 95 % CI: 0.02–0.37) and was not significantly associated with reduced stimulant use among people who used crack/cocaine daily (aOR = 0.33, 95 % CI: 0.04–2.86). Females were significantly more likely to report decreased crystal methamphetamine use during periods of cannabis use (aOR = 0.10, 95 % CI: 0.02–0.56) (Table 2). In the second sub-analyses, cannabis use to manage stimulant cravings was significantly associated with reduced stimulant use among participants aged < 44 years (aOR = 0.26, 95 % CI: 0.08, 0.84) and participants aged ≥ 44 years (aOR = 0.21, 95 % CI: 0.05, 0.89) (Supplementary Table 2).

Table 1.

Logistic regression analysis of factors associated with self-reported reductions in stimulant use during periods of cannabis use (n = 297).

Unadjusted Adjusted
Characteristic OR (95 % CI) p - value OR (95 % CI) p - value
Age
(per 5 years older) 1.01 (0.93, 1.10) 0.884 1.02 (0.87, 1.20) 0.802
Sex at birth
(female vs. male) 0.69 (0.42, 1.14) 0.146 1.95 (0.69, 5.52) 0.210
White ancestry
(yes vs. BIPOC) 0.92 (0.57, 1.46) 0.712 0.61 (0.26, 1.47) 0.274
Employmenta
(yes vs. no) 1.53 (0.93, 2.50) 0.093 1.26 (0.52, 3.04) 0.613
Homlessnessa
(yes vs. no) 1.60 (0.90, 2.85) 0.110 1.98 (0.73, 5.39) 0.179
Cannabis usea
(≥daily vs. < daily) 0.46 (0.29, 0.74) 0.001 0.26 (0.11, 0.62) 0.002
High THC cannabis usea
(yes vs. high CBD) 1.12 (0.44, 2.85) 0.816 1.18 (0.39, 3.57) 0.771
Cannabis use to manage stimulant cravingsa
(yes vs. no) 0.20 (0.12, 0.33) <0.001 0.24 (0.10, 0.56) 0.001
Open in a new tab

Notes: CI = confidence interval

a

Refers to activities in the 6 months prior to the follow-up interview

BIPOC = Black, Indigenous and people of colour

bold text refers to P-values < 0.05.

Table 2.

Logistic regression analysis of factors associated with self-reported reductions in crack/cocaine use and crystal methamphetamine use during periods of cannabis use (n = 297).

Crack/cocaine Crystal methamphetamine use
Characteristic OR (95 % CI) p - value OR (95 % CI) p - value
Age
(per 5 years older) 1.06 (0.65, 1.72) 0.830 1.09 (0.75, 1.59) 0.659
Sex at birth
(female vs. male) 0.04 (0.01, 1.00) 0.051 0.10 (0.02, 0.56) 0.009
White ancestry
(yes vs. BIPOC) 0.09 (0.01, 1.43) 0.088 0.97 (0.23, 4.19) 0.972
Employmenta
(yes vs. no) 0.88 (0.11, 6.75) 0.901 2.16 (0.33, 14.24) 0.422
Homlessnessa
(yes vs. no) 0.99 (0.05,19.48) 0.996 2.07 (0.42, 10.07) 0.369
Cannabis usea
(≥daily vs. < daily) 1.11 (0.15, 8.44) 0.919 0.34 (0.08, 1.42) 0.140
High THC cannabis usea
(yes vs. high CBD) 0.78 (0.60, 1.02) 0.066 0.95 (0.81, 1.10) 0.478
Cannabis use to manage stimulant cravingsa
(yes vs. no) 0.33 (0.04, 2.86) 0.314 0.08 (0.02, 0.37) 0.001
Open in a new tab

Notes: CI = confidence interval

a

Refers to activities in the 6 months prior to the follow-up interview

BIPOC = Black, Indigenous and people of colour

bold text refers to P-values < 0.05.

5. DISCUSSION

We observed that participants who used cannabis to manage stimulant cravings were significantly more likely to report decreased stimulant use during periods of cannabis use, and this association was primarily driven by the association between cannabis use and crystal methamphetamine use. These findings contribute to existing preclinical and epidemiological evidence investigating the potential of cannabinoids to be used as a substitute for stimulants (Daldegan-Bueno et al., 2021, Daldegan-Bueno et al., 2022). To our knowledge, this is one of the first studies to analyze the association between intentional cannabis substitution and patterns of unregulated stimulant use (Socias et al., 2017). Previous cohort studies have found that cannabis use was associated with decreases in the likelihood of initiating injection stimulant use among youth and intentional substitution has been linked to decreases in crack-cocaine use among PWUD (Socias et al., 2017, Reddon et al., 2018). Other evidence has shown that cannabis use was linked to reduced symptoms of craving among people living with crack-cocaine dependence and was reported to produce positive changes in substance use behaviour (Labigalini et al., 1999). Our findings build on this work by showing that intentional cannabis use to manage stimulant cravings was associated with decreases in stimulant use among PWUD. However, there are other studies that have found increased harms associated with cannabis use among people who use unregulated stimulants. Among people in inpatient care for cocaine use disorder, frequent cannabis use was associated with increased cocaine craving and withdrawal (Daldegan-Bueno et al., 2021). Chronic cannabis dependence may also increase crack-cocaine cravings and relapse risk among people living with poly-substance use disorders (Viola et al., 2014, Lindsay et al., 2009). This heterogeneity may suggest that the impacts of cannabis use on stimulant use could depend on how cannabis is used (e.g., recreational vs. therapeutic), the type of cannabis used (e.g., THC vs. CBD), other concurrent substance use (e.g., crack/cocaine vs. amphetamines) and the stage of substance dependence that cannabis is used (e.g., initiation, dependence, withdrawal, recovery). While there are concerns about replacing one for of substance use for another, the risks associated with cannabis substitution should be considered in the context of polysubstance use among PWUD (Lucas et al., 2019). The cumulative probability of transition to dependence is estimated at 9–13 % among people who use cannabis, 21 % among people who use cocaine and 68 % among people who use nicotine, with the rate of transition occurring more rapidly among cocaine users (Lopez-Quintero, et al., 2011, Leung et al., 2020). If cannabis use is associated decreases in stimulant use, it could be used as a harm reduction strategy to limit exposure to the toxic drug supply, although additional research is needed to clarify these mixed results and identify longer-term outcomes associated with these cannabis use behaviours (Lucas et al., 2019, Mok et al., 2021, Knill et al., 2022, Fischer et al., 2015).

We also found that females were more likely to report decreased stimulant use during periods of cannabis use, which builds on existing evidence demonstrating sex-based differences in cannabis use and outcomes (Cuttler et al., 2016). While men are more likely to use cannabis and develop cannabis dependence, women are more likely to use cannabis for medicinal purposes and recent evidence from our study setting found that women were also more likely to report decreases in opioid use during periods of cannabis use (Reddon et al., 2023, Cuttler et al., 2016). Further clinical trials, prospective studies and qualitative studies will be helpful to clarify these effects among PWUD (Fischer et al., 2015).

The observation of an inverse association between stimulant use and daily cannabis use adds potentially valuable detail to our understanding of how cannabis-based interventions might be applied in the context of harm reduction, and contrasts to proposed “safer use” guidelines which caution against use in excess of once or twice per week (Fischer et al., 2017). The potentially salutary impacts of daily cannabis use also highlights issues regarding equity and access, as daily cannabis use may not be affordable or otherwise feasible for many of those who might be most likely to benefit, which has been shown in previous studies (Lake et al., 2020). Further research would be helpful to examine sustainable pathways to cannabis access (e.g., self-production, subsidized access).

In the absence of established pharmacotherapies for the treatment of stimulant use disorders, further investigation of the harm reduction and therapeutic applications of cannabis use is warranted to address the harms of stimulant use (Fischer et al., 2015). CBD in particular may have distinct therapeutic potential for stimulant use based on the anxiolytic and anti-psychotic properties, carries a low risk of adverse events, and can be offered in multiple formulations (Fischer et al., 2015, Daldegan-Bueno et al., 2021). However, high-CBD products continue to be more expensive than high-THC cannabis, which likely creates a significant barrier to access among PWUD (Lake et al., 2020, Mahamad et al., 2020). Based on the preliminary evidence of therapeutic cannabis use among PWUD, community-led cannabis distribution projects have emerged that distribute low-cost cannabis to structurally marginalized PWUD in an effort to improve equitable access to therapeutic cannabis use and divert people away from other potentially contaminated substances (Valleriani et al., 2020). While cannabis substitution for stimulant use may not be appropriate or appealing to all cannabis users, our findings that this was a prevalent motive for use (reported by 45 % of stimulant users) and was associated with self-reported decreases in stimulant use lend support to these initiatives and signal that further rigorous evaluation of the therapeutic effects of cannabis for stimulant use is warranted (Fischer et al., 2015, Daldegan-Bueno et al., 2021).

Limitations of this study include the cross-sectional design, non-random recruitment of participants and measuring substance use behaviours by self-report. As a result, our findings may not be generalizable to other populations of PWUD. Since this was an observational study, we were not able to establish causal relationships, we cannot be certain about the direction of these associations, the results may not be durable over time and residual confounding may have influenced the associations we observed. Although self-reported substance use measures among PWUD have demonstrated strong validity when compared to biomarker assessment, socially desirable reporting and recall bias may have influenced the measurement of these stigmatized behaviours (Ahmad et al., 2014, Darke, 1998). Changes in stimulant use were self-attributed with reference to periods of cannabis use and were not independently assessed. As a result, this measure may have been somewhat complementary to the exposure variable (cannabis use to manage stimulant cravings) and increased the likelihood of these variables being significantly associated. However, participants were provided with response options to indicate if their stimulant use either increased or decreased when using cannabis so that both directions of association (e.g., increased or decreased stimulant use during periods of cannabis use) could be assessed. Similar measures of cannabis and unregulated drug use have also been used in previous studies to analyze cannabis substitution patterns (Reddon et al., 2023). The associations we observed may also be specific to the substance use patterns (e.g., high prevalence of cannabis and polysubstance use) and policy (e.g., legalized recreational cannabis use) in the local study setting (Lake et al., 2017).

In summary, we observed that cannabis use to manage stimulant cravings was associated with self-assessed decreases in stimulant use among people who used crystal methamphetamine daily. These findings contribute to divergent preclinical, observational and qualitative evidence evaluating the harms and potential benefits of cannabinoids in the context of polysubstance use and suggest that additional rigorous observational studies and clinical trials are warranted to corroborate these effects.

Supplementary Material

Supplementary Table

HIGHLIGHTS.

  • We investigated the use of cannabis to manage cravings for stimulants among PWUD.

  • Cannabis use to manage stimulant cravings was reported by 134 (45.1%) participants.

  • Cannabis use was associated with decreases in crystal methamphetamine use.

  • Cannabis use was not associated with decreases in crack-cocaine use.

Acknowledgements

The authors thank the study participants for their contribution to the research, as well as current and past researchers and staff. We would specifically like to thank Steve Kain, Cristy Zonneveld, Emma McHugh and Ana Prado for their research and administrative support. All authors respectfully acknowledge that they live and work on the unceded traditional territory of the Coast Salish Peoples, including the traditional territories of the xʷməθkwəy̓əm (Musqueam), Skwxwú7mesh (Squamish), and Səl|ílwətaɬ (Tsleil-Waututh) Nations. The study was supported by the US National Institutes of Health (U01-DA038886, U01-DA0251525) and the Canadian Institutes of Health Research (CIHR; MOP– 286532, RL2– 183257).

Role of funding sources

This research was undertaken, in part, thanks to funding from the Canada Research Chairs program through a Tier 1 Canada Research Chair in Inner City Medicine. H. Reddon is supported by a CIHR postdoctoral fellowship. M-J. Milloy is supported in part by the US National Institutes of Health (U01-DA021525.) M-JM is the Canopy Growth professor of cannabis science at the University of British Columbia (UBC), a position created using unstructured arms’ length gifts to the university from Canopy Growth Corporation, a licensed producer of cannabis, and the Government of British Columbia’s Ministry of Mental Health and Addictions. K. Hayashi holds the St. Paul’s Hospital Chair in Substance Use Research and is supported in part by the NIH (U01DA038886), a Michael Smith Foundation for Health Research (MSFHR) Scholar Award, and the St. Paul’s Hospital Foundation. M.E. Socias is supported by a MSFHR/St Paul’s Foundation Scholar Award. All funders had no role in the study design, data collection, analysis or interpretation of the data, writing of the article or submission for publication.

Footnotes

CRediT authorship contribution statement

Hudson Reddon: Conceptualization, Methodology, Data curation, Formal analysis, Writing – original draft. Maria Eugenia Socias: Writing – review & editing. Kora Debeck: Project administration, Funding acquisition, Writing – review & editing. Kanna Hayashi: Project administration, Funding acquisition, Writing – review & editing. Zach Walsh: Funding acquisition, Conceptualization, Methodology, Writing – review & editing, Supervision. M.-J. Milloy: Project administration, Funding acquisition, Conceptualization, Methodology, Writing – review & editing, Supervision.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix A. Supplementary material

Data availability

The authors do not have permission to share data.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplementary Table
NIHMS1969049-supplement-Supplementary_Table.pdf (70.4KB, pdf)

Data Availability Statement

The authors do not have permission to share data.

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