A lot of the drug agencies we work in will be quite used to getting urine samples off clients and discussing the results with them. However, how many of us discuss in any detail (if we bother to test for it in the first place) one of the most common drugs to show up on those results;- Cannabis.

Research shows that up to 60% of opiate users (clients attending Methadone programmes or those currently using heroin) use cannabis on a regular basis. (Nirenberg 1996, Saxon 1993). Could there be other reasons for its use beyond the euphoric effects, could it actually be helping clients either control their heroin use or help them with withdrawal symptoms?

Cannabis as a therapeutic agent

THC the psychoactive chemical in cannabis is already widely recognised as a use therapeutic aid in various illness’, Glaucoma, severe morning sickness, anti asthmatic, severe pain in cancer patients, nausea and pain with AIDS patients, to name some of them.

However what is not often mentioned is that it also has a history of being used in the treatment of withdrawal symptoms from opiates, being quite widely used in the late 1800’s.

Furthermore, research in the 1940,s and 50’s suggested that cannabis lessened or eliminated opiate withdrawal symptoms, with the client being in a better frame of mind, his spirits elevated, his physical condition more rapidly rehabilitated, and he wished to resume his occupation sooner (Allentuck 1942) or its therapeutic value being attributed to improved appetite, greater sleep, euphoria, and a reduction of the intensity or elimination of abstinence phenomena. More recently, laboratory tests have shown that it may be helpful in reducing the onset of withdrawal symptoms (Hemendra 1976, Hine 1975).

From these results it would seem possible that clients are self medicating themselves with Cannibis, with it having a positive outcome on reducing withdrawal symptoms .

The research.

Only a brief time was available to gather data so both qualitative and quantitative methods were used. Forty male clients from both non-statutory and statutory agencies were included, hoping that a good cross section of heroin and methadone users would be achieved. The main crux of the research was looking at how often clients used cannabis, whether they found it beneficial with a range of withdrawal symptoms and how they presently came into contact with it, so the following hypotheses were tested:-

Heroin users use cannabis to help with heroin withdrawal symptoms when attempting to reduce or stop their heroin use. Cannabis is becoming more difficult to obtain by heroin users. Less availability of cannabis leads to an increase in heroin use amongst heroin users.

Findings

Some interesting results were thrown up , with 70% of clients saying they used cannabis regularly and of these the heroin users using more frequently than the methadone users. A picture was painted of all users, but especially the heroin users, feeling rather remote from the cannabis scene, saying that it was sold by different dealers to those who sold heroin and that they felt ostracised by the cannabis users themselves.

This seems to have led to a situation where 80% of the clients said that sometimes it was harder to find cannabis to buy than heroin and that many had bought heroin because there was no cannabis around.

Much as with the previously mentioned research, clients found cannabis to be helpful in relieving some of the opiate withdrawal symptoms, though primarily with the more psychological ones rather than the more physical, with three quarters of respondents saying cannabis relives symptoms generally.

When using cannabis along with heroin it was felt best to use after having had the heroin rather than before, this increased the positive effects of both drugs whereas if used before it could dampen down effects .

Discussion

The three hypotheses seem to have been proven as far as a research project of this size can ascertain.

Heroin users certainly seemed to be making conscious decisions as to when to use cannabis, recognising that by using before heroin use would improve the euphoric effects but also if already withdrawing from heroin that it could make the physical symptoms worse. This would seem to indicate a quite high level of management of their drugs for desired effect.

The research also brought up questions around why methadone users would be using cannabis.

68% of methadone users were using frequently, but only 22% felt that it increased the euphoria from methadone, (compared to 82.5% of all clients saying it increased the high from heroin) indicating that they must be using it for other reasons, probably direct effects of cannabis itself, but also it could help with the psychological side of remaining on and stable on methadone.

There would then be a strong resemblance between why clients tend to ask for benzodiazepines, ie. for help to sleep, get them through the day, help them relax etc. and the use of cannabis.

Although it is obviously best if clients do work around dealing with these issues, are the results from this research indicative of more support being needed?

According to the 1994 figures for drug seizures and offences (Home Office 1994), 83% of all drug offences in the UK in 1994 involved cannabis, with the total number of cannabis offences tripling between 1984 and 1994.

Obviously these figures can be read in different ways, but whichever a lot of police time is being spent on cannabis related offences. If Howard Parker (1993) is correct and there is a process of normalisation underway in respect of adolescent recreational misuse, then figures such as mine (which indicate that 63% of heroin users know at least one person who started using heroin through a lack of cannabis), would show that there is a risk of heroin becoming the drug in this normalisation rather then cannabis, primarily as a result of strong policy towards cannabis.

There also seems little reason for this strong policing when cannabis dealers have little or no contact with heroin itself. Certainly not selling it and hence introducing cannabis users to heroin.

It would seem better to encourage this divide, as is done in the Netherlands, leading to a structure where if cannabis is more readily available it may well mean it is more widely used for its therapeutic value in opiate withdrawal (the subject for my next research project).
See
"Here, if you want cannabis you go to a coffee shop.
In other countries if you want it you have to go to a man who might try to sell you heroin or cocaine as well."

TREATMENT IMPLICATIONS

Reports from the local drug database shows a level of cannabis use amongst heroin users as 29%, (compared to the 73% in my sample), clearly a case of under reporting by staff completing database forms, or under reporting (due to not being asked, not feeling they could mention it?) from clients themselves. How often do we ask clients about their cannabis use, and what could we learn from knowing more about how it fits into their other drug using behaviour.

At the very least we should be including it in ongoing assessments of clients and seeing if there is work that could be done around reducing their heroin intake through cannabis use. Obviously this could put staff in a difficult situation, if advising clients to use what is still another illicit drug, but the situation is no different to that of advising on using heroin and the nest ways of cutting it down, it is all part of the harm reduction programme we run with clients. There seems little if no danger from cannabis use increasing the amount of heroin used by clients, whether they use it to increase the euphoric effect (and hence use less heroin for the same effect) or if they use it when finding it hard to cope with self induced withdrawal symptoms when trying to cut down.