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August 31, 2016

Is Cannabis a Safer Alternative to Drugs and Alcohol?

Cannabis can be harmful if you use it irresponsibly, but it’s nowhere near as destructive as alcohol for example. With wider availability, cannabis can and will become a substance of choice – and likely save a lot of lives (and livers) in the process. Substituting cannabis for prescription drugs, alcohol and other substances among medical marijuana patients:

The impact of contextual factors
Recent years have witnessed increased attention to how cannabis use impacts the use of other psychoactive substances. The present study examines the use of cannabis as a substitute for alcohol, illicit substances and prescription drugs among 473 adults who use cannabis for therapeutic purposes.

Design and Methods
The Cannabis Access for Medical Purposes Survey is a 414-question cross-sectional survey that was available to Canadian medical marijuana patients online and by hard copy in 2011 and 2012 to gather information on patient demographics, medical conditions and symptoms, patterns of medical marijuana use, cannabis substitution and barriers to access to medical marijuana.

Substituting cannabis for one or more of alcohol, illicit drugs or prescription drugs was reported by 87% of respondents, with 80.3% reporting substitution for prescription drugs, 51.7% for alcohol, and 32.6% for illicit substances. Respondents who reported substituting cannabis for prescription drugs were more likely to report difficulty affording sufficient quantities of cannabis, and patients under 40 years of age were more likely to substitute cannabis for all three classes of substance than older patients.

Discussion and Conclusions
The finding that cannabis was substituted for all three classes of substances suggests that the medical use of cannabis may play a harm reduction role in the context of use of these substances, and may have implications for abstinence-based substance use treatment approaches. Further research should seek to differentiate between biomedical substitution for prescription pharmaceuticals and psychoactive drug substitution, and to elucidate the mechanisms behind both.

Substitute therapies for tobacco (e.g. nicotine replacement therapy) and heroin (e.g. methadone) have been available for some time, while analogous substitutes for alcohol have been more elusive. A recent review of medication substitutes for alcohol defines seven criteria for substitution therapy (Chick and Nutt, 2012). At the same time, a growing number of studies suggest that cannabis could be considered as a substitute therapy for alcohol (Mikuriya, 2004; Charlton, 2005; Reiman, 2009). Some even suggest that medical cannabis be prescribed to individuals attempting to reduce alcohol use (Mikuriya, 2004; Charlton, 2005). In light of the recent movements toward cannabis legalization in the USA, which imply that cannabis use may become more commonplace, especially among heavy drinkers (Clements and Daryal, 2005), we need to better understand whether cannabis can substitute for alcohol among individuals who are trying to reduce drinking.

This paper assesses whether cannabis satisfies conditions for substitution therapy according to the seven criteria outlined by Chick and Nutt (2012). Please note that although the impetus is to assess the viability of cannabis as a substitute treatment or medication, the majority of the studies cited do not necessarily regard medically prescribed cannabis. However, this is not a limitation per se because naturalistic cannabis use is probably more generalizable to 'real-life' conditions.

Criteria for Substitution Treatment and Common Substitution Medications

Chick and Nutt (2012) recent review of medication substitutes outlined the following criteria for any substitution treatment:

It should reduce alcohol use and related harms.

It should ideally be free of harms, or at least less harmful than alcohol.

Misuse should be less than that of alcohol.

It should be shown that it can substitute for alcohol and not be used along with alcohol.

It should be safer in overdose than alcohol.

It should ideally not potentiate the effects of alcohol especially if either drug is taken in overdose.

It should offer significant health economic benefits.

Benzodiazepines and γ-aminobutyric acid (GABA) agonists have been considered the most promising substitutes for alcohol (Chick and Nutt, 2012). However, results from a series of studies by Zack et al. implied that benzodiazepines may prolong the risk of relapse (Zack et al., 1999, 2006; Poulos and Zack, 2004). Furthermore, the American Psychiatric Association Task Force has cautioned against prescribing benzodiazepines to patients with a history of substance abuse or dependence because of their high-addiction potential.

Drugs such as sodium oxybate and baclofen also affect the GABAergic system and therefore have some pharmacological properties similar to alcohol. GABA agonists like baclofen may suppress cravings, reduce drinking and improve liver function (Addolorato et al., 2002, 2005, 2007a, b), but also increase alcohol-induced sedation and can severely impact daily functioning if not carefully titrated. Sodium oxybate, a drug similar to the street drug γ-hydroxybutyric acid (GHB), has also met controversy due to its addiction potential (Chick and Nutt, 2012). Other GABA-acting drugs (e.g. clomethiazole) were used in the 1970–1980s and found to cause less liver damage than alcohol; however, these drugs can be fatal when mixed with alcohol (Chick and Nutt, 2012).

Although benzodiazepines and GABA agonists may be medically acceptable substitutes for alcohol, they can have unpleasant side effects for many people. In addition, these drugs can lead to dependence and health risks if alcohol is ingested simultaneously (US Food and Drug Administration, 2013). Based on these premises, Charlton (2005) suggested that cannabis might be 'a safer and less anti-social substitute' for drinking. Charlton claimed that most people use alcohol to achieve certain psychological effects, and that they will choose equally effective substitutes as long as they are available, legal and socially acceptable. Charlton stated that alcohol policy should aim to reduce related medical and social harms and that 'lifestyle drug substitution' or substituting safer but equally effective agents, could be one way to reduce harms (Charlton, 2005).

(Benzodiazepines (BZD, BZs), sometimes called "benzos", are a class of psychoactive drugs whose core chemical structure is the fusion of a benzene ring and a diazepine ring. The first such drug, chlordiazepoxide (Librium), was discovered accidentally by Leo Sternbach in 1955, and made available in 1960 by Hoffmann–La Roche, which, since 1963, has also marketed the benzodiazepine diazepam (Valium). In 1977 benzodiazepines were globally the most prescribed medications.

Benzodiazepines enhance the effect of the neurotransmitter gamma-aminobutyric acid (GABA) at the GABAA receptor, resulting in sedative, hypnotic (sleep-inducing), anxiolytic (anti-anxiety), anticonvulsant, and muscle relaxant properties. High doses of many shorter-acting benzodiazepines may also cause anterograde amnesia and dissociation. These properties make benzodiazepines useful in treating anxiety, insomnia, agitation, seizures, muscle spasms, alcohol withdrawal and as a premedication for medical or dental procedures. Benzodiazepines are categorized as either short-, intermediate-, or long-acting. Short- and intermediate-acting benzodiazepines are preferred for the treatment of insomnia; longer-acting benzodiazepines are recommended for the treatment of anxiety.

Benzodiazepines are generally viewed as safe and effective for short-term use, although cognitive impairment and paradoxical effects such as aggression or behavioral disinhibition occasionally occur. A minority of people can have paradoxical reactions such as worsened agitation or panic.[6] Long-term use is controversial because of concerns about adverse psychological and physical effects, decreasing effectiveness, and physical dependence and withdrawal. As a result of adverse effects associated with the long-term use of benzodiazepines, withdrawal from benzodiazepines, in general, leads to improved physical and mental health. The elderly are at an increased risk of suffering from both short- and long-term adverse effects, and as a result, all benzodiazepines are listed in the Beers List of inappropriate medications for older adults.

There is controversy concerning the safety of benzodiazepines in pregnancy. While they are not major teratogens, uncertainty remains as to whether they cause cleft palate in a small number of babies and whether neurobehavioural effects occur as a result of prenatal exposure; they are known to cause withdrawal symptoms in the newborn. Benzodiazepines can be taken in overdoses and can cause dangerous deep unconsciousness. However, they are much less toxic than their predecessors, the barbiturates, and death rarely results when a benzodiazepine is the only drug taken; however, when combined with other central nervous system (CNS) depressants such as ethanol and opioids, the potential for toxicity and fatal overdose increases. Benzodiazepines are commonly misused and taken in combination with other drugs of abuse

Alcohol withdrawal
Chlordiazepoxide is the most commonly used benzodiazepine for alcohol detoxification, but diazepam may be used as an alternative. Both are used in the detoxification of individuals who are motivated to stop drinking, and are prescribed for a short period of time to reduce the risks of developing tolerance and dependence to the benzodiazepine medication itself. The benzodiazepines with a longer half-life make detoxification more tolerable, and dangerous (and potentially lethal) alcohol withdrawal effects are less likely to occur. On the other hand, short-acting benzodiazepines may lead to breakthrough seizures, and are, therefore, not recommended for detoxification in an outpatient setting. Oxazepam and lorazepam are often used in patients at risk of drug accumulation, in particular, the elderly and those with cirrhosis, because they are metabolized differently from other benzodiazepines, through conjugation.

Benzodiazepines are the preferred choice in the management of alcohol withdrawal syndrome, in particular, for the prevention and treatment of the dangerous complication of seizures and in subduing severe delirium. Lorazepam is the only benzodiazepine with predictable intramuscular absorption and it is the most effective in preventing and controlling acute seizures.

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