Harm Reduction in Cannabis Use, with Nicholas Felicione and Jessica Kruger

In this episode, guests Dr. Jessica Kruger and Dr. Nicholas Felicione, discuss the complex topic of cannabis use harm reduction. They explore the challenges and complexities of harm reduction in the evolving landscape of cannabis legalization, highlighting the need for more research and evidence-based strategies to educate consumers and reduce potential risks associated with cannabis use. The conversation touches on various aspects of cannabis, from product testing and labeling to the possible substitution of cannabis for other, more harmful substances, all within the context of promoting health equity and responsible consumption.

Guests:
Jessica Kruger, PhD, MCHES
Director, Teaching Innovation and Excellence | School of Public Health and Health Professions
Clinical Associate Professor | Department of Community Health and Health Behavior

Nicholas Felicione, PhD
Assistant Professor | Department of Community Health and Health Behavior

Credits:
Hosts/Writers: Jessica Kruger, PhD, MCHES | Nicholas Felicione, PhD
Guest:  Jessica Kruger, PhD, MCHES | Nicholas Felicione, PhD
Production Assistant/Audio Editor: Sarah Robinson, MPH 
Theme Music: Dr. Sungmin Shin, DMA 

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Transcript

Sarah Robinson  0:00 
Hello and welcome back to another episode of Buffalo HealthCast, the official health equity podcast of the University at Buffalo's School of Public Health and Health Professions. My name is Sarah Robinson, your production assistant for Buffalo HealthCast. Today we have a compelling and critical discussion that aligns perfectly with our semester-long exploration of substance use disorders and addiction. We're honored to welcome back two distinguished experts who need no introduction to some of our dedicated listeners. We have former cohost, the brilliant Dr. Jessica Kruger and a new guest, Dr. Nicholas Felicione, who is a newer Assistant Professor in the Department of Community Health and Health Behavior here at UB. Together they bring a wealth of knowledge and experience to our podcast episode, and they're ready to shed light on a topic of immense significance. Today's episode is not just timely, it's essential. We're diving headfirst into the world of cannabis use harm reduction. As the societal perspective on cannabis evolves, so too does the need for informed responsible consumption. Dr. Kruger and Dr. Felicione will provide us with invaluable insights into the harm reduction strategies that can make a significant impact on the lives of those grappling with cannabis use, and by extension, substance use disorders. So without further ado, let's get started on this enlightening conversation between Dr. Jessica Kruger and Dr. Nicholas Felicione in another episode of Buffalo HealthCast.

Jessica Kruger  1:43 
Hi, I'm Dr. Jessica Kruger, Clinical Associate Professor in the Department of Community Health and Health Behavior, and a cannabis researcher and today I'm joined by a colleague.

Nicholas Felicione  1:54 
Hi, I'm Nick Felicione, I'm an assistant professor in the Department of Community Health and Health Behavior. I'm primarily a tobacco researcher, and I also teach our department's course on harm reduction.

Jessica Kruger  2:08 
Tell me a little bit more about that course.

Nicholas Felicione  2:11 
Yeah, so harm reduction is really looking at ways to reduce the public health and individual harms of substance use and other potentially harmful behaviors without necessarily requiring people be abstinent. Because not everyone is ready or able to quit substances. So we try to figure out ways to reduce harm so we can keep people alive for longer periods of time and improve their health and standing. So throughout the course, we cover a variety of substances like tobacco, alcohol, cannabis, and some other risky behaviors to see what are public health measures we can do to reduce the negative impacts of drugs. And throughout the course, we also had conversations with community experts. I know Cheryll Moore was on the HealthCast, we had her come in, we had a couple of people from Evergreen Health come talk to us about the work they're doing. And we also had some advocates from Vocal NY who do work on advocating for reduced drug penalties, harm reduction, and things like that come talk to us, really just to get a comprehensive look about what's going on in our area and the broader national and international scope of harm reduction.

Jessica Kruger  3:26 
Sounds like a really important course for public health students to think about the broad impact of harm reduction and how it can be applied.

Nicholas Felicione  3:35 
Yeah, it's an newer way of thinking about it. It's generally been a bottom up movement that's really been led by drug users really for decades. But now more recently, it's becoming more ingrained in society and more recognized. There's more funding for harm reduction research, and we're starting to see more policies enacted, aiming to reduce harms. And we think of little things like Erie County distributing fentanyl test strips, things like Never Use Alone hotlines. And just any ways we can to reach people who may be engaging in risky behavior to try to help them improve their health, mental health or even like economic and societal situation.

Jessica Kruger  4:22 
Sounds like there's a broad impact of these harm reduction efforts.

Nicholas Felicione  4:26 
Yeah, it can really reach a lot of people. Because it can apply to so many things, like even from a basic stance, we think of seatbelts as a harm reduction measure, you know, people used to just drive without them and eventually we realized including seatbelts would potentially reduce the risks of driving in cars. A lot of people were resistant at first, but now it's just such a standard safety measure that everyone accepts it. So the goal is to expand this to more and more risky behaviors and try to have a large population impact.

Jessica Kruger  5:03 
That's great. So today we wanted to talk a little bit about cannabis and cannabis harm reduction. I think you have some questions around that. Do you want to tell me a little bit more about what you're interested in?

Nicholas Felicione  5:16 
Yeah. So before we really get into harm reduction, I'm just interested to know more about what are some of the main harms that may result from cannabis use?

Jessica Kruger  5:26 
Yeah, so people use cannabis in a lot of different ways. And for those who may be unaware of the terminology, oftentimes we hear the term "marijuana use". In this, we will be using "cannabis," because it's the more appropriate name for the plant. And so when people are using cannabis, depending on how they're using, depends on what type of harm reduction. So if someone is smoking a joint or a blunt, that can result in them really taking in some of those negative components when you burn a product. And so therefore, you know, one way to reduce harms of that is to have people use a different way such as vaping, cannabis, or even using edibles. But both of those have challenges when it comes to it because of dosing and what people like to feel. So what have you heard around this? Or what have you seen in your work?

Nicholas Felicione  6:23 
So I similarly agree, there are some methods that seem like they could be beneficial, but everything's kind of a trade off. So while combustible products like smoking are likely to lead to the most harms, because you get exposed to things like carbon monoxide and other combustion byproducts that could be carcinogenic. It doesn't mean other methods aren't necessarily safe. So when we're talking about edibles, people may overdose, or not overdose in the way we traditionally think about it. But they may take too much and feel unpleasant, or have negative mental health effects and things. So we really need to, I think, just in general, be thinking about these things and researching these things. So we know what type of guidance to provide people. And make sure it's evidence based. So we are actually reducing harms.

Jessica Kruger  7:21 
Yeah, most definitely. I think that the key word there is evidence based, and that's something that we're very much lacking in the cannabis community. Right. We get a lot of this from anecdotal evidence, survey evidence, but the challenge is researching cannabis right now.

Nicholas Felicione  7:38 
Yeah. So that was one of my next questions actually is, you know, cannabis is becoming increasingly legalized, more people are seeming to use it. But it's still classified as a Schedule I drug by the FDA, which makes it really hard to do research, particularly directly administering cannabis to patients or participants in a lab. So given those limitations, what can we do to research cannabis harm reduction and understand what's effective and what's not?

Jessica Kruger  8:10 
You know, that's a challenging question, because we're getting self reported data. And so many of our studies are utilizing self reported information. So asking people, what they're using, how they're using it, and also having them answer how they feel about the harms of this product. And oftentimes, there can be a mismatch, right between what they feel is harmful versus what we do know is harmful. But balancing that and understanding what people may know what they may not know, and also their chosen use of administration of the drug. So I think it becomes a really sticky situation where we need the availability to do some of this research to really understand is vaping safer, or are using edibles a better way when looking at different products. And the challenge with this is cannabis is so complex, right? We have Delta-8, we have Delta-9, THC-O. I mean, it's an alphabet soup out there. So it's hard to actually have blanket suggestions because in some of our more recent research, we're finding that THC-O might in fact not be safer when vaped because it's an acetate, and so it's, we have to really as public health professionals step back and be careful by what we're saying on this because depending on the product, which continually evolve, depends on what we should say with harm reduction.

Nicholas Felicione  9:49 
So related to that and the proliferation of these alternative cannabinoids that are not Delta-9, which is the primary psychoactive component, when we're are typically thinking about cannabis. How does legalization play a role here? Like do we see that legalized states people are less likely to be diverted to these alternatives? Or is there an issue where legalization kind of sends the message that this is okay to use and may worsen the public health impact of cannabis use?

Jessica Kruger  10:21 
In our studies, we found that in states that are legalized, you see less of a use of some of these alternative cannabinoids so because people have access to Delta-9 THC, they're less likely to use Delta-8 or THC-O or THC-JD, I could go on for hours. But really, because of that access, they they are able to get Delta-9. And we do see in places that have restrictions on recreational and medical cannabis, you see people turning to those alternatives. THC-A is one that we're seeing that a lot of people are using in other states. And there's not a lot known about these alternatives. And so we really have to step back and think about how legalization can protect people from the testing of the product, but also what they're actually able to get.

Nicholas Felicione  11:14 
Yeah, it's a really tricky situation for policymakers, for public health experts to monitor all these things, because the market evolves kind of in a faster way than we keep keep up with. But I think it's a salient point that legalization and this legal market is maybe a way to help reduce harms, because when we put in sensible regulations, these are meant to try to control the product and may be helpful, help people's use. So when you get cannabis product from a legal dispensary as opposed to a black market or like a gray market, we know that it's been lab tested, and we know what components are in it, and that it meets the below thresholds for pesticides and other harmful constituents. And along with that, there's also economic and societal costs that legalization help offsets. So in the harm reduction course, we talk a bit about the war on drugs, and how that's really led to continued harms of drug use and kind of the lessened impact of potential harm reduction. So I kind of think about that here, where now in a legalized state, we're not incarcerating people for cannabis. So while we're maybe not necessarily thinking of health harms, there's other harms we may be reducing as well.

Jessica Kruger  12:40 
Yeah, I think that's a great point that you bring up, especially around incarceration, the war on drugs. Here in New York, they've actually provide a license to be open to folks who may have previously had a drug charge, which is an equity focus program. We're seeing a pretty slow rollout, which is a challenge to this, but it's starting to hopefully change the view and get people into the industry in a legal way.

Nicholas Felicione  13:11 
Yeah, and I think that's interesting that you mentioned kind of the equity and kind of social justice aspect. So other than legalization efforts, are there other ways that cannabis harm reduction can kind of further promote health equity?

Jessica Kruger  13:29 
I don't know. That's a great question. What have you seen in your work?

Nicholas Felicione  13:34 
So I also don't really have an answer to that right now. And so I think that makes a point, though, that this is an area for necessary research and public health work. I mean, kind of, like we've mentioned, we know that marginalized and vulnerable populations have been negatively impacted by cannabis laws. So at least in that sense, we see a health equity perspective, potentially, but I just don't think we know enough, again, like we mentioned about evidence based harm reduction, to know how it's going to apply and potentially further health equity or not.

Jessica Kruger  14:15 
Yeah, I think that's a good point. Right? There's a lot that we don't know about cannabis, and especially in states as they're rolling out legalization, medical, and even, you know, where we can look to some states who have even gone beyond that with Colorado and legalizing even more substances. How is this impacting some of the most vulnerable people? Right, and what are those impacts? And how will we see that over time? And I don't know that anyone has a crystal ball to answer that question.

Nicholas Felicione  14:48 
Yeah, it's a difficult situation to be in and I do wonder how much we can kind of look to other models to learn from them. So can we look at data from Canada or other potential countries that have had legal cannabis for longer than individual states have here? Or can we look at states that have been early in legalization efforts and learn from what's went well, and what hasn't went well there to further kind of develop cannabis harm reduction.

Jessica Kruger  15:23 
And that's a great holistic way for us to really think about this and explore more, right? Because if we don't have a change in the Schedule I classification of cannabis, we're going to have to get creative.

Nicholas Felicione  15:36 
Yeah, so thinking of that, given what we don't know, can we learn anything from other substances and harm reduction efforts for those? Like, opioids seem really different when we talk about things like supervised injection facilities and distributing Narcan and distributing fentanyl test strips. I'm not sure if there's a direct parallel there. But also, are there things maybe we can learn from tobacco and like less harmful tobacco products in comparison to cigarettes, to try to inform how we approach cannabis?

Jessica Kruger  16:13 
I think there's a lot that we know and these other areas are beginning to understand. And some of the things I think about when it comes to the opioid epidemic are definitely testing and testing of products, which we're starting to see come through with cannabis. And people are more informed about how and why they should have their cannabis tested. So when they're buying from a legal distributor, you can usually scan a QR code to see what is in that product. That's not the case, if you get it from your neighbor down the road. And informing consumers, I think is really key in educating consumers about what those dangers are, whether it's pesticides, whether it's mold, and this is especially important for those who are using it for medical purposes, right, we wouldn't want someone who's going through chemotherapy using this to reduce nausea to be ingesting high levels of mold and pesticides. So really ensuring that the source is safe, or safer, and ensuring that they know the product that they're using. Oftentimes in our surveys, when we ask people how much they're using, they don't know, they don't know how much THC versus CBD. And so being able to provide that education for consumers, I think is really key and one of the next steps that we really need to think about.

Nicholas Felicione  17:37 
And I think that also ties into the research difficulties we talked about. Because when we're relying on a lot of self report data, and we're asking people, you know, what is in your product? What is your, do you even know, like what cannabinoids you're consuming? Do you know how much you're consuming? If we can't get reliable data on that, it becomes really difficult. So I think that information aspect and making sure things are clear and labeled and understandable to the consumer is a really important first step towards moving that way. And I also just think about as a tobacco researcher, like what we can learn from the tobacco world, because even though cannabis is more intoxicating than tobacco, the primary forms for each are combustible methods, which we know are not good. Now, at the same time, while vaping seems a lot healthier than or less harmful than cigarette smoking, there's still a lot of debate in the field on how much less harmful, or maybe it's less harmful, but people might be consuming it more because it's more discreet. So I think just keeping an eye on what's going on in tobacco and tobacco harm reduction and how that's developing might help us inform potential interventions for cannabis harm reduction.

Jessica Kruger  19:01 
That's a great point. And, you know, we have so much more research when it comes to the tobacco and tobacco industry that we should definitely look back and see what what's happening there and evolving and what can be implemented in this landscape.

Nicholas Felicione  19:17 
I agree completely. So I'm also just wondering, you know, thinking from a public health perspective, we want to have broad impacts, but also we know a lot of how we enact policies and individual behavioral measures for harm reduction may differ. So I'm just wondering if you have any thoughts on like, what can an individual do to potentially reduce their harms? And what can public health professionals and policy makers do on a broader scale to try to reduce the harms of cannabis use?

Jessica Kruger  19:53 
It's an excellent question. From the individual level. I think a lot of it comes to education and being an informed consumer and knowing what you are utilizing. And that means sometimes people have to do a little bit of research on their own, which I think comes to the policy side, we should have labels that describe this information and provide this information in an easily accessible way, including in print that's visible for those who may have vision issues. One of the largest groups of folks using cannabis are older adults, and having instructions on what a serving size means if someone is using an edible, and also the duration of that high, which can be different depending on the type of modality. So I think that really comes into policy around labeling, and also distribution. There's some pretty wild practices when it comes out to marketing cannabis. There is no standard marketing kind of system or rules around it. We're seeing different things in different states, unlike Canada, which you mentioned, who has a broader scope of an information on marketing. And so we have to worry about this being marketed to children. And there are some states that do have regulations around that, others do not. But this is something that pediatricians are really worried about, and the age of onset of use. From an individual level, I think besides being educated, I think it's really important to think about where your product is coming from, and making sure that you are being that informed consumer, making sure that you're getting products that are tested, and that you're being able to get help if you need it. So some people may continue to use and have funded a challenge to get off of cannabis. There's been a lot of debate about is cannabis addictive? And so I think we need to think about all of those aspects when it comes to consumption, harm reduction from that individual level.

Nicholas Felicione  22:01 
Yeah, I think that's a really important point, like, we're talking about methods that, well, if we switch from smoking to vaping, maybe that's healthier. But there's a broader perspective than that. And when we're thinking about, you know, fighting against attractive marketing, we need good effective prevention education campaigns and messaging going out to teens and adolescents about the potential risks of cannabis use. Because really, the best way to reduce the harms of something is to get someone never to start. And on the other side, we need good treatment options for people who can't control their use or are experiencing harms. And this is where I hope legalization efforts can help too. Because some of that the tax revenue and things like that can be funded back into treatment and prevention campaigns to try to reduce those harms of cannabis use.

Jessica Kruger  23:04 
Most definitely. I was just in Minnesota, and they have legalized cannabis market. In fact, you can go into an establishment that sells alcohol and they also sell THC beverages. What do you think we should do around that?

Nicholas Felicione  23:21 
Yeah, so that's a really interesting question. And I think this is an important challenge. But I think for the most part regulated dispensary should only be able to carry cannabis products and really nothing else to make sure it's clear and not confusing, and we don't get people mixing products. And that's really a challenge in the way current markets are currently set up. And just the difficulty in enforcing a lot of these things. Because a lot of stores operate in kind of this black/gray market where they're kind of skirting around legal loopholes, and selling cannabis out of vape shops, and they're also selling other substances that are in these legal gray areas like kratom. Some of them are even starting to sell like analogs of psychedelic compounds. So you're going somewhere that's really supposed to be like a vape shop. And now you can also purchase cannabis products and products that may have opioid like properties in cannabis and products that may have psychedelic like properties. So again, I think this just ties into the importance of regulation. But after regulation, like surveillance and enforcement is really key, but also a huge challenge because I've seen reports that there may be like 10 to 30,000 kind of gray market cannabis retailers in New York alone. So how we even approach dealing with a situation like that. I don't have the answer. And I don't know if anyone does.

Jessica Kruger  25:06 
Yeah, that's so true, right. And I like how you brought up that there's a challenge with that gray or black market. But also it can be confusing if you're going to a bar and you can buy a cannabis beverage and also co-use with alcohol. What is that doing? And how is that increasing harm versus reducing harm?

Nicholas Felicione  25:26 
Yeah, and I think we're still learning more about that, like, I'm starting to branch my research a little bit more into co-use of even nicotine and cannabis. Because we see people will coadminister these products sometimes. And it really just makes both of them feel better. They're like the cannabis makes my nicotine feel a little bit stronger. The nicotine maybe helps offset some of the cognitive impairments of my cannabis use. But we also see it may lead people to use more or become more dependent. So I think there really are concerns with coadministration of multiple substances. But it also becomes difficult because when we have two legal substances like alcohol and cannabis, or like tobacco and cannabis, how do we stop people from using them together?

Jessica Kruger  26:21 
I think that brings up a really excellent point and just highlights the complexities of these substances and harm reduction related to these substances. I don't know - any last thoughts on this topic that you want to bring up?

Nicholas Felicione  26:36 
Yeah, I think one last point. And I don't know if we have a lot of information about this, but I've seen a couple of papers is - do we see that people might try to use cannabis as harm reduction for more harmful substances. So do people try to substitute cannabis for opioid use or stimulant use like methamphetamines as a way to control their use and reduce the harms of those.

Jessica Kruger  27:02 
Our studies do show people are substituting cannabis for pharmaceuticals. And on one hand, that seems like a great thing. On the other hand, it's very terrifying, because ultimately, if someone is on an opioid, and they quit, that can have some pretty harmful effects. Also, we see people reducing their psychiatric medications and substituting for cannabis, which those need to be incredibly monitored as someone is titrating down. And so while on one hand, it sounds like a great harm reduction campaign for opioids, I also think we have to look at this with a very skeptical lens and really think about the safety when it comes to people substituting and also what are they substituting it with? How are they using it? How much are they using? So there's a lot more questions and answers.

Nicholas Felicione  27:59 
Yeah, I think that's a great point. And, again, just kind of ties into this theme of we need more research. So I've seen, you know, qualitative interviews with people who use illicit stimulants and opioids, who say they use cannabis to try to reduce their cravings or reduce their use. But in reality, we don't know exactly what's happening. So maybe in ways it makes them feel better. But are they still using the same amount of methamphetamine or fentanyl? And now just adding cannabis on top of that? Are they truly reducing the use of these maybe more harmful substances and substituting cannabis? And I think that's an important question that we don't have the answer to yet. Hopefully, one day, yeah. So again, I think that just ties into our plug for the need for continued research, the need for regular surveillance of what's going on, particularly as markets become more legalized, understanding what's going right and what's going wrong. You talked about labeling, like, we need good studies on what is understandable to consumers. And when they read a label, do they know what it means? And how can we help them understand what it means? So overall, I think we just need a lot more comprehensive public health efforts in this field, to really get a good picture of what's going on.

Jessica Kruger  29:28 
Sounds like years and years of research that needs to be done, and also a lot of job security for those in cannabis research. Well, thanks so much. This has been a lot of fun to talk about this topic. And it's been great to have a different perspective from someone who studies tobacco and also other drugs.

Nicholas Felicione  29:50 
Yeah, I enjoyed having this conversation. It's always interesting to think about these things and you know, cannabis is becoming In a more normalized substance, basically by the day, so I think it's just really important to engage in these conversations and think what public health professionals can do to try to mitigate any potential harms that may come along with that.