\u201cIf I knew I could get that every hour instead of alcohol, I would take the cannabis\u201d: need and feasibility of cannabis substitution implementation in Canadian managed alcohol programs

Bernie Pauly,Meaghan Brown,Cindy Rose,Russell Callaghan,Clifton Chow,Christy Sutherland,Michelle Jordan,Ashley Wettlaufer,Gerald Thomas,Karen Urbanoski,Brittany Graham,Tim Stockwell

doi:10.1186/s12954-021-00512-5

Abstract

BackgroundWhile there is robust evidence for strategies to reduce harms of illicit drug use, less attention has been paid to alcohol harm reduction for people experiencing severe alcohol use disorder (AUD), homelessness, and street-based illicit drinking. Managed Alcohol Programs (MAPs) provide safer and regulated sources of alcohol and other supports within a harm reduction framework. To reduce the impacts of heavy long-term alcohol use among MAP participants, cannabis substitution has been identified as a potential therapeutic tool.MethodsTo determine the feasibility of cannabis substitution, we conducted a pre-implementation mixed-methods study utilizing structured surveys and open-ended interviews. Data were collected from MAP organizational leaders (n = 7), program participants (n = 19), staff and managers (n = 17) across 6 MAPs in Canada. We used the Consolidated Framework for Implementation Research (CFIR) to inform and organize our analysis.ResultsFive themes describing feasibility of CSP implementation in MAPs were identified. The first theme describes the characteristics of potential CSP participants. Among MAP participants, 63% (n = 12) were already substituting cannabis for alcohol, most often on a weekly basis (n = 8, 42.1%), for alcohol cravings (n = 15, 78.9%,) and withdrawal (n = 10, 52.6%). Most MAP participants expressed willingness to participate in a CSP (n = 16, 84.2%). The second theme describes the characteristics of a feasible and preferred CSP model according to participants and staff. Participants preferred staff administration of dry, smoked cannabis, followed by edibles and capsules with replacement of some doses of alcohol through a partial substitution model. Themes three and four highlight organizational and contextual factors related to feasibility of implementing CSPs. MAP participants requested peer, social, and counselling supports. Staff requested education resources and enhanced clinical staffing. Critically, program staff and leaders identified that sustainable funding and inexpensive, legal, and reliable sourcing of cannabis are needed to support CSP implementation.ConclusionCannabis substitution was considered feasible by all three groups and in some MAPs residents are already using cannabis. Partial substitution of cannabis for doses of alcohol was preferred. All three groups identified a need for additional supports for implementation including peer support, staff education, and counselling. Sourcing and funding cannabis were identified as primary challenges to successful CSP implementation in MAPs.

Highlights

While there is robust evidence for strategies to reduce harms of illicit drug use, less attention has been paid to alcohol harm reduction for people experiencing severe alcohol use disorder (AUD), homelessness, and streetbased illicit drinking
Sourcing and funding cannabis were identified as primary challenges to successful Cannabis substitution program (CSP) implementation in Managed alcohol programs (MAP)
If I have cannabis, I will use cannabis This theme includes findings pertaining to Consolidated Framework for Implementation Research (CFIR) constructs: personal attributes; knowledge and beliefs about CSP, and individual stage of change

Summary

Introduction

While there is robust evidence for strategies to reduce harms of illicit drug use, less attention has been paid to alcohol harm reduction for people experiencing severe alcohol use disorder (AUD), homelessness, and streetbased illicit drinking. “Acute” physical harms from alcohol include poisonings and unintentional injuries, while the list of “chronic” physical harms and alcohol-attributable diseases is lengthy, including liver disease, cancers, strokes, and gastrointestinal diseases [2]. These harms generally increase with a dose–response relationship to volume of alcohol consumption [2]. “Risky” drinking occurs across the population with social acceptance of drinking practices informally regulated by social and cultural norms This is apparent when comparing social acceptance toward binge drinking among privileged populations and in leisure settings (e.g., public binge drinking among college and university students) [4] to stigma and discrimination toward visible binge drinking among people experiencing poverty and/or homelessness [5]. The costs and distribution of these harms are shaped by socioeconomic, political, and other contextual factors, may be more publicly visible and concentrated among those with high levels of structural disadvantage [6,7,8,9]

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