The fluidity of substance use in the context of a Small Island Developing State – Cannabis use as harm reduction in Saint Lucia

Interrogating the concurrency of drug use and the reasoning behind substance substitution or “poly drug use” often focuses on the negative effects of drug interactions.

In the popular press review of published research literature, cannabis, when mentioned at all, is that of an aside, as one of the other drugs used, possibly the journalist, generalising the negative interactions of small sample to the whole.

The community of people who use drugs and the treatment providers who work with them have long recognised the moderating effect of cannabis on crack cocaine use. Since 1998, the evidence that supports this community belief has been made possible by the availability of cohorts of medical marijuana users to study.  The findings are being published in scientific journals and are attracting a more positive reception from the popular press, largely due to the wide acceptance of “medical marijuana” in a majority of States of the USA.

This review focuses on one usually neglected aspect of poly drug use, the beneficial qualities of cannabis in mitigating harms and reducing the compulsion to use often associated with the use of smokable cocaine.

The study where the Saint Lucian data is drawn was undertaken in the capital city of Castries in the small island developing state of Saint Lucia, located in the Windward Island Archipelago in the West Indies where, similar to the rest of the Commonwealth Caribbean, rum and cannabis like cocaine share three important characteristics; they are of high quality, inexpensive and readily available. Interestingly these 3 characteristics have served as a protective factor for the country and region as they discourage the wholesale introduction of new substances in any quantity. If Saint Lucia may be used as an example, the availability of reasonably priced, high quality plant based substances deter motivation to engage in manufacturing synthetics. Supporting this theory is the fact that there are no synthetic drugs manufactured in Saint Lucia despite the relative ease of acquiring the necessary precursors.

In 2007 I posed drug use questions to 262 people who were selected for the study based on 2 criteria, they smoked crack cocaine and were homeless. Not one respondent answered that crack was the sole substance used in the past 30 days. The use of multiple substances was the norm with three other substances being the most common, tobacco, cannabis and alcohol, in that order.

The origins of substances in Saint Lucia

Of the four substances commonly used in the Caribbean, only tobacco was indigenous at the time of European ‘discovery’. Columbus, on his first voyage to the Americas, found Taino Indians indigenous to Cuba smoking the tobacco leaf rolled into what we now call a cigar. Thus tobacco was introduced into Europe.

Sugar Cane was introduced into the Caribbean in the 16^th century. For ease of transport it was converted at the source into molasses and then rum, primarily for export. Rum, to this day, holds a prime place in Caribbean tourism marketing of pleasure, using the mantra of Sun, Fun and Rum. The economic dependence on rum production secured it place as the region’s main alcoholic beverage to this day. Illustrating this, the Guyanese born Minister of Tourism of Saint Lucia was recently quoted as saying “‘We really are a rum-producing people and historically we really are a rum drinking people and rum is a very proud and main part of our heritage,”

Given the country and regional struggle to address the non-communicable diseases of hypertension and diabetes, this was an important notice that the economic primacy of rum took precedence despite the scientific evidence that alcohol contributes heavily to the aetiology of these illnesses and the strong evidence that the disinhibiting qualities of alcohol promotes violence, domestic abuse and traffic fatalities, alcohol remains a mainstay of tourism promotion.

Cannabis was next to arrive in the Caribbean, travelling with the migration of the East Indian indentured workers who arrived in Saint Lucia and other islands to replace the labour lost after the abolition of slavery in the English empire in1843. Cannabis was used medicinally, for fibre and as a work aid and remains a mainstay of traditional “bush” medicine. Contrary to the prevailing thought that  cannabis use makes one lethargic, cannabis is consumed by many unskilled labourer and farm worker, who claim they  work more diligently when under the influence of cannabis.

Cocaine has had a much more recent introduction into Saint Lucia. Cocaine hydrochloride is an alkaloid extracted from the leaves of the coca plant. The salt form is processed into a white powder primarily for export. A smokable form is a residual by-product of producing the powder, a smokable paste, “paco” commonly used throughout Latin America. As the residual from the manufacture of cocaine it is inexpensive and commonly used in urban spaces. The other form of smokable cocaine is an after market product produced by stripping the hydrochloride module from the cocaine powder using bicarbonate of soda. In the Caribbean the ‘skim’ from transhipments, the product that is used to pay for the transhipment, is often converted to its smokable form for quick sale on the street. There is little evidence of powder cocaine use outside the upper classes and tourists.

In the case of Cocaine, it was not discovery, agricultural exploitation or migration that resulted in a new substance being introduced but law enforcement, logistics and geography. The Caribbean is located strategically between the cocaine producing countries of South America and the cocaine consuming countries of North America and Europe. Saint Lucia’s central location and close proximity to the French Overseas Department of Martinique makes it a key staging areas for cocaine entering France for onward distribution throughout the United Kingdom and Europe.

As commercial airlift expanded in the 1980s, direct non-stop flights from the Caribbean to major cities became common. The Caribbean’s diverse colonial histories that accompanied travel market demand guided the first destinations of these non-stop routes. Destinations were correlated to a  colonial past, London for the Commonwealth, the former Dutch colonies first destination was Amsterdam and the Oversea’s Departments of France were only a domestic flight, albeit 9 hours, direct into Paris. As direct flights from cocaine producing countries became targets for greater scrutiny, cocaine was moved into other countries and then onward. For Saint Lucia, cocaine first moved to London, non stop direct on passenger planes until that route was disrupted by Operation Airbridge[1]. Subsequently, cocaine transhipped Saint Lucia and travelled by sea to Martinique for onward transport to Paris on one of the many carriers servicing Fort de France airport (FdF).

Illustrating its neo-colonialist position, cocaine and cannabis largely entered the US through Mexico, with some cocaine/cannabis shipments coming from Columbia entering Miami through the Bahamas, mimicking the same smuggling routes used by alcohol traffickers during the US prohibition era in the 1920’s.

The unintended consequences of an expanded War on Drug

The USA domestic war on drugs began in earnest during the Nixon Presidency with the passage of the US Controlled Substance Act of 1970 and the formation of the DEA in 1973.

During the Regan administration (1980-88) the War on Drugs was expanded globally.   The proximity of South American, its coca production and the historical precedent of the Monroe Doctrine all supported a new offensive strategy. Determined not to wait until drugs arrived at the boarder, the US applied military assets to take the eradication and interdiction to the source.

Initially US cocaine interdictions focused on Central America and the western Caribbean, displacing the transhipments to the small islands of Eastern Caribbean. With a largely unpatrolled coast line these islands became a mid point in the transhipment of cocaine to the consuming countries of the global north.

Saint Lucia, following historical ties became a gateway for cocaine entering the UK, first directly on non-stop carriers and later through Martinique to Paris and onward to London that remained the ultimate destination for most of the cocaine passing through Saint Lucia. Fishing pirogue, pleasure craft and yachts transported cocaine from Saint Lucia across the narrow channel, where the illicit cargo was transferred to “domestic” flights direct into Paris and then via the Eurostar into London. A British Government Representative in the mid 1990s confided in the author that more cocaine was interdicted at Waterloo from Paris than in Gatwick. The French gendarmes in Fort de France plugged some of these holes but cocaine and other contraband still transits the channel, as canoes have for 1000s of years, the cocaine for onward shipment, oblivious to the European imposed borders.

As cocaine flowed through Saint Lucia for transhipment, the compensation provided to local ‘facilitators”  was changed from cash to “in-kind”. Cocaine became the currency of payment and soon the local market was awash with high grade powder cocaine, most of which was converted into its smokable form, crack cocaine for sale locally. Because the goal was the conversion of cocaine into cash as quickly as possible, the price of power cocaine and crack were set below the prices charged in the métropole. Interestingly the retail price of a “rock” crack cocaine has remained stable at $5.00 XCD ($1.80 USD) for the past 30 years, despite the erosion of the purchasing power of that $5.00.

“Just Say No” How US funded Demand Reduction impacted consumption patterns

Globalisation was just taking hold in the late 80s. Preferential treatment of agricultural products was ending and the WTO lead free trade regimes began to take hold. The information age was yet to reach. There was no internet in Saint Lucia until 1995 and evidenced based information on drugs was difficult to obtain, its availability limited and its content skewed ideologically.

The USA, directly and through the UNDCP/UNODC, funded antidrug campaigns that depicted all drugs as of equal harm and all deadly. The implication was that you could die as easily from cannabis as from heroin or cocaine. Cannabis focused anti drug messaging also claimed cannabis made the user slow and lethargic.

In Saint Lucia these assumptions were met with scepticism by the local population who knew from experience that they were false. Almost everyone in Saint Lucia knew someone who used cannabis. Cannabis was an integral part of the local pharmacopeia, an aid to performing manual labour and an important part in the sacramental, recreation and relaxation life of many people. Given the evidence at hand these anti drug messages were widely ignored by a sizable minority of the local population.

When smokable cocaine came on the scene, the cannabis smoking population had already been inoculated to distrust the US/UNODC anti-drug messaging associated with cannabis. That same messaging contained information on the harms associated with crack cocaine. So a naïve population accustomed to smoking cannabis with no deleterious effect, looked at the “Just Say No” posters and thought; “if the facts on cannabis are erroneous, the messaging on crack must be the same.

That was the local context in which smokable cocaine first arrived in Saint Lucia, a new product to be smoked like cannabis. It was readily available, flowing freely and caught the nation and the region unaware of the actual harms. Existing cannabis brokers were used to sell crack which encouraged substance switching and experimentation.

The ideological influence of the war on drugs on the research agenda

The adoption of the Single Convention on Narcotic Drugs in 1961 spurred a new impetus in the research of cannabis. From 1960 to 1970 there was a marked increase in cannabis research by the US Public Health Service (USPH) as research into the public health consequences of drug use was encouraged by the Convention.

The scheduling of cannabis as a Schedule 1 drug in the USA (1970) and the moving of the drugs research from the USPHS with a focus on public health to the newly formed National Institute of Drug Abuse, whose remit was prevention, signalled an ideological shift research the research agenda. Requests for proposals (RFP) were crafted to garner research initiatives that focused on the negative consequences of drug use. Little focus was given to investigating the beneficial and therapeutic value of cannabis.

During those dark days, NIDA and related NIH funded drugs research focused almost exclusively on the hazards of the use of cannabis rather than any benefits of its medicinal use.[2] [3]  NIH crafted the various Request for Proposals (RFP) to attract research aimed a exposing the most negative consequences of cannabis. Any data that was found that went against the drug war orthodoxy was relegated to obscurity. If the research reported positive attributes to cannabis and negated the studies original hypothesis, NIH could not stop the work from being published but it was shunned, NIH failing to engage their public relations machinery to publicise science not in keeping with the “war on drugs” ideology. As a result good science did not receive the attention it deserved.  This was particularly true of research on cannabis.  As stated above research into the medicinal value of cannabis began to recover after the 30 year hiatus in 2000 when medical cannabis started to become available.

The discovery and mapping of the endocannabiniod system only began to occur at the close of the 20^th century and laid the foundation for the introduction of therapeutic and medicinal cannabis. The availability of medicinal cannabis of regulated strengths enabled scientists to interrogate the medicinal value of cannabis on health issues in a controlled fashion. A similar law in British Colombia legalised medical marijuana in 2001 and made scientific investigation possible in that jurisdiction. Since then the proliferation of legally sanctioned medical and recreational cannabis has allowed an ever increasing number of scientists to investigate the therapeutic value of cannabis in various domains. It is within that context that this article explores the positive effect the “poly drug use” of cannabis and smokable cocaine.

Cannabis as harm reduction for crack cocaine

The first research in this area was conducted in those jurisdictions when smokable cocaine and cannabis were common. The research cited here is started in Brazil and the Caribbean in the 1990s and was followed in California and Vancouver BC, commencing within a decade of the legalisation of medical marijuana in those jurisdictions.

Regardless of the ideological influence on the research agenda of the NIH, research on cannabis outside the US continued with Brazilian researchers leading the way. Brazil experienced one of the first waves of social dislocation regarding the use of smokable cocaine in a highly criminalised environment and was desperate for solutions. The first published study in the Journal of Psychoactive Drugs validated the observations of Caribbean drug treatment service providers. They published the results of a small Brazilian study of “25 male patients who where strongly addicted to crack”. Over a nine month period 68% or 17 individuals ceased to use crack and reported that the use of cannabis had reduced their craving symptoms and produced subjective and concrete changes in their behaviour.”[4]. This study, conducted outside of the US, created quite a stir especially among NIH funded researchers who were eager to undertake their own work in this area. The Brazilian work was concurrent with research on cannabis being done in Jamaica in the 1990s and early 2000s.

An ethnographic study of women who smoked crack cocaine and cannabis in inner city of Kingston Jamaica examined the social and economic conditions that influenced cocaine use. The introduction of cocaine to Jamaica followed the same pattern as Saint Lucia, transshipment, in-kind payments and inoculation to harm through mix-messaging. The women in this group reported using a mix of cannabis and crack known in Jamaica as a seasoned spliff. As in Saint Lucia, and common throughout the English speaking Caribbean, this differentiation between using a pipe or smoking your crack mixed with cannabis in a season spliff was stark. Jamaicans made a clear distinction. Pipers were seen as undisciplined, lazy and even unhygienic person while people who mixed went largely unnoticed and were subject to much less stigma except from pipers. People who piped their crack looked down on people who mixed as not real “crack heads” because cannabis dulled the rush. This supported what we found in Saint Lucia and throughout the Caribbean

That same study reported the subject of the “seasoned spliff of particular interest because it represented the intersection of two opposing Jamaican metaphors: ganja as the healing of the nation and crack as the epitome of Babylon and all that is wrong with the world. Cannabis was viewed as the healing herb, a soothing balm to calm the demons released by the Babylon devil – crack.

All the women in this study reported that they used cannabis to reduce, pause or cease their crack use. The report was made to the US Embassy in Kingston with a recommendation that cannabis be consider as part of a solution for reducing harms associated with crack cocaine use. The conclusion of this work “Whether or not the use of ganja is a remedy for crack addition in the biological, psychological or sociological sense, programs that fail to acknowledge the different cultural meanings and experiences attached to these two illicit substances ultimately will lose credibility with the very population they need to serve.” These suggest the need to reframe “poly drug use” within the cultural meanings that place cannabis in Jamaica as a medicine and a sacrament[5],

In a 2007 behavioural sero prevalence study I conduced in Castries Saint Lucia we had similar results as Dreher with a larger mixed sample of 262 people who were homeless and who all smoked crack cocaine while 73% reported smoking cannabis. Respondents were asked if cannabis could be used as a substitution for crack with 38% answering yes and 52% no, the balance not knowing. Licit polydrug use was also high 83% of the respondents in the survey reported using tobacco, in a wide range, from a few cigarettes a day to 40+. Tobacco was used alone, mixed with cannabis and as an ‘ash bed” to rest crack rocks on when smoking straight crack rocks. Tobacco may also be mixed with cannabis and crack in “seasoned spliffs”.

Alcohol use was the second most consumed substance reported by the respondents. Strong Rum / “Spice” is the most popular drink of the respondents. 100 ml of a 150 proof rum with a enfusion of local barks, twigs, herbs and spices such as cinnamon. Other ingredients may include a scorpion, snake or centipede. In the vernacular the drink is reputed to help “get your nature up” and is considered an aphrodisiac, most likely for its disinhibiting qualities. It is sold by vendors on the street with little regulation.

Cannabis was the second most used substance reported with almost three quarters of the sample reporting cannabis use often mixed with crack in a joint form.

The motivation for not using cannabis was interesting. While the majority of individuals surveyed did smoke both, more than 25% did not use cannabis. Some persons specifically noted that they did not use cannabis because it reduced the intensity of the effects of the crack. They perceived this as a negative quality but others reported that they specifically used cannabis and crack together for that very reason; it moderated the intensity of the effects.  These findings were very similar to what Dreher found in Jamaica 15 years prior.

The individuals who did not use cannabis used alcohol if they could not get crack or if they wanted to sleep. Other individuals because of their mind “set” found that the use of crack helped them cope and these individuals used with more regularity. In our studies these individuals were also more likely to self report a mental health issue and inpatient time at the psychiatric hospital. For numerous reasons, after a few admittances into the psychiatric hospital some individuals would just find themselves in the city of Castries, where crack was available and numerous income generating opportunities existed.

In addition to alcohol, tobacco and cannabis use, there were the odd respondents who answered yes to lifetime use of an assortment of other drugs. In the 2007 BSS in Castries, 12.5% of the 264 respondents answered yes to using other substances. When that occurred we would pause the quantitative portion of the survey and delve deeper. For ecstasy and heroin tourist were mentioned the most often as the source. Heroin experimentation was also more likely to occur with Saint Lucians who previously lived in urban spaces in North America or Europe.

Crack was and remains available for sale in every community in Saint Lucia. The only community of cannabis smokers to differentiate cannabis from crack was the Rastafarian community. From the beginning Rasta viewed cannabis as a sacrament and crack as a poison visited upon the people by ‘Babylon” as the modern, technological world was referred. They were the only community in Saint Lucia to educated their children on the differences between the two substances, strongly discouraging their brethren from use. Rasta was the only community in which the sellers of cannabis did not vend crack also

In the US Reiman operationalises drug substitution as the conscious choice to use one drug (legal or illicit) instead of, or in conjunction with, another due to issues such as: perceived safety; level of addiction potential; effectiveness in relieving symptoms; access and level of acceptance. In that 2009 study Reiman reported on a cohort of medical marijuana users in Berkley California and propensity to substitute cannabis for other drugs. On analysis of the data it was shown that many of the medical marijuana users had substituted cannabis for alcohol (40%) other illicit substances (26%), prescription drugs (66%),demonstrating cannabis’ suitability as a substitution for other substances shown to be more harmful to the body.[6]

In Salvador, Brazil Andrade et.al.,[7] identified several key reasons for the widespread use of ‘pitilho’ a cigarette of cannabis and smokable cocaine.

The mix was reported to:

• reduce the negative pharmaco-behavioural and physical effects of crack use,
• was more economical to use,
• provided the users with better control over their behaviours thus
  • decreasing their vulnerability for violence
  • improving their position within the sub-culture.

The researchers concluded that the ‘Pitilho’ offered several relevant short-term benefits to users and therefore may constitute a potentially important ‘harm reduction’ tool in an area where little other targeted prevention measures exist.

Another small qualitative study in Brazil of 27persons who smoked crack cocaine and who combined its use with marijuana[8] and reported on in 2015. The interviewees reported that the combination of crack cocaine use with marijuana provided “protection” such as reduced undesirable effects, improved sleep and appetite and reduced craving for crack cocaine. The respondents also not that it allowed them to recover some quality of life.

In 2015 finding were reported of a small qualitative study done in the San Francisco Bay area of “baby boomer”s, individuals born between the 1946-1964. The study participants described using cannabis as a safer alternative for alcohol, illicit drugs and pharmaceuticals based on their perceptions of less adverse side effects, low-risk for addiction and greater effectiveness at relieving symptoms, such as chronic pain. The study concluded that cannabis substitution can be an effective harm reduction method for those who are unable or unwilling to stop using drugs completely.[9]

Vancouver, Socias[10] et al used data drawn from three prospective cohorts of people who use drugs. They selected data from 122 individuals who reported intentional cannabis use to reduce crack use between 2012 and 2015. They found that a people successful used cannabis to reduce crack use. This study also recommended further clinical research to assess the potential of cannabinoids for the treatment of crack use disorders is warranted.

Harm reduction for Crack

Harm reduction, originally focused solely as a prevention strategy to reduce the direct transmission of HIV via the sharing of non-sterile syringes. This was accomplished by the distribution of sterile syringes and advocating for safe injection spaces.

Cannabis has held a strange place in the harm reduction movement. Many harm reduction service providers used cannabis, often instead of other drugs which they may have preferred but often said “cannabis was just easier on them” for regular use saving other drug use for special occasions.

The resistance on the part of the UNODC to support the use of cannabis as an evidence based harm reduction strategy is unfortunate especially in light of the enlightened policy outlined in the Technical Guide For Injecting Drug Use.[11], Opioid substitution therapy, sterile needle and syringe distribution have been endorsed but there is no acknowledgement of the science of cannabis as a mediator of harms associated with crack cocaine use. Cannabis as substitution therapy remained taboo, evoking laughter or derision.

Among many people who use smokable cocaine, there has always been a long held strategy that smoking a mixture of crack and cannabis[12] mitigated some of the health and behavioural extremes that smoking or “piping” crack straight often lead to.

Cannabis has shown promise as an alternative to crack cocaine use. Each one of the articles cited called for more research into cannabis as harm reduction strategy for smokable cocaine use.

Cannabis use to mitigate harms associated with smoking crack

Since the introduction of harm reduction to the Caribbean in the mid 90s, professionals and colleagues throughout the Caribbean working in the field of drug treatment have quietly conceded that cannabis use mitigated harms associated with crack use. While making clear that their programmes were based on 100% abstinence from all substances they considered cannabis the preferred alternative, over alcohol, for those people who used crack and continued to express a ‘need’ to use some substance.

Service providers should note that cannabis use should be considered therapeutic and for those individuals who turn to cannabis use should not be discouraged from this.

[1] The Cocaine Trade – Home Affairs Committee, UK Parlement, chapter 6 paragraph 124.  https://publications.parliament.uk/pa/cm200910/cmselect/cmhaff/74/7412.htm

[2] Nutt DJ, King LA, Nichols DE. Effects of Schedule I drug laws on neuroscience research and treatment innovation. Nature Rev Neurosci 2013; 14: 577-585.

[3] Gross M. Drugs prohibition is criminals’ gain, neuroscience’s loss. Nature Curr Biol 2013; 23: R585-R588.

[4] Labigalini E Jr, et. Al., Therapeutic use of cannabis by crack addicts in Brazil.

J Psychoactive Drugs. 1999 Oct-Dec;31(4):451-5. https://www.ncbi.nlm.nih.gov/pubmed/10681113 accessed 7 Feb, 2018

[5] Dreher, M. (2002). Crack heads and roots daughters: The therapeutic use of cannabis in Jamaica. Journal of Cannabis Therapeutics, 2(3-4), 121-133.

[6] Reiman, 2009, https://harmreductionjournal.biomedcentral.com/articles/10.1186/1477-7517-6-35

[7] Andrade, T., Santiago, L., Amari, E., & Fischer, B. (2011). ‘What a pity!’- Exploring the use of ‘pitilho’ as harm reduction among crack users in Salvador, Brazil.’ Drugs: Education, Prevention, and Policy, 18(5), 382-386. http://www.tandfonline.com/doi/abs/10.3109/09687637.2010.506898

[8] Goncalves, J. R. & Nappo, S. A. (2015). Factors that lead to the use of crack cocaine in combination with marijuana in Brazil: A qualitative study. BMC Public Health, 15. https://www.ncbi.nlm.nih.gov/pubmed/26209238

[9] Lau, N., Sales, P., Averill, S., Murphy, F., Sato, S.-O., & Murphy, S. (2015). A safer alternative: Cannabis substitution as harm reduction. Drug and Alcohol Review, 34, 654-659. https://www.ncbi.nlm.nih.gov/pubmed/25919477

[10] Socias, M. E., Kerr, T., Wood, E., Dong, H., Lake, S., Hayashi, K., … & Milloy, M.-J. (2017). Intentional cannabis use to reduce crack cocaine in a Canadian setting: A longitudinal analysis. Addictive Behaviors, 72, 138-143. doi: 10.1016/j.addbeh.2017.04.006

[11] WHO, UNODC, UNAIDS technical guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users – 2012 revision

[12] Smokeable cocaine and cannabis mixed into a cigarette is called a seasoned spliff, spranger or black joint in the English speaking Caribbean.