The Hole That Needs Filling: Cannabis as Chronic Maintenance in an Era of Failed Abstinence

Abstract

After thirty years of ethnographic fieldwork, clinical observation, and hundreds of structured interviews with people who smoke crack cocaine in the Caribbean, I have concluded that the addiction treatment industry and the international drug control system that supports it, is built on a foundational lie: the assumption that abstinence is achievable for everyone who uses drugs.

Some people have a permanent constitutional need for chemical regulation. Call it a hole. Call it a void. Call it whatever you want, the reality is that a significant minority of people who use substances will never achieve total abstinence, and the collective refusal to acknowledge this fact continues to cause incalculable harm.

In Saint Lucia, as in much of the Caribbean, cannabis has long served as an euphoriant for many and a sacrament to Rastafarians. Cannabis has also entered the realm of substitution therapy. Many people who used to smoke crack have turned to smoking cannabis daily as an alternative. For people who continued to smoke crack about a third found that mixing crack with cannabis   served as a harm reduction tool. Referred to as a “black joint” or a “seasoned spliff”, the mixture moderated the rush and help manage the crash.

Treatment providers have quietly conceded that using cannabis instead of crack was a positive change while still maintaining abstinence-only programmes that contradict that clinical experience.

It is time to acknowledge that for some people, substitution maintenance is not a relapse or a failure but the necessity, a way to achieve a balance. Cannabis needs to be legal and available for people to use as an alternative to more harmful substances such as crack or alcohol. The system needs to support innovative substitution therapies, including cannabis and where appropriate, prescription stimulants for people who’s crack use is self medication for the treatment of their ADHD.

Introduction: Why Writing This Paper

I have worked in the Caribbean drug field since 1998. I have served on the UN Reference Group on HIV and IDU, advised CARICOM, PAHO, UNODC, and the World Bank on issued related to drugs and HIV. I have conducted assessments and research in prisons throughout CARICOM memberstates, on the streets and in the drop in centres of Castries, Kingston and Port of Spain. The research has garnered over 400 interviews with people who smoke crack cocaine, many of them homeless, many of them sex workers, many of them living with HIV.

I am also a humanitarian and human rights advocate. I was awarded a UK Queen’s Birthday Honour (MBE) for my work in this field.

Writing this is not an academic exercise but a testament to people who have died, have stabilized and continue to seek comfort from low threshold interventions that don’t require abstinence to obtain assistance. And I am tired of the drug treatment establishment’s constant drm beat that abstinence is the only acceptable outcome.

Part One: The Hole

The addiction medicine industry has spent decades debating whether addiction is a “disease” or a “choice.” This debate is a distraction. It avoids the real question: why do some people continue using substances despite often catastrophic consequences, while others sample substances occasionally? Why do some people eat two squares of a chocolate bar and put the balance away for later consumption while others must consume the entire bar in one sitting?

My observation from forty years of fieldwork is that some people have a constitutional void, a restlessness, an existential unease, that makes simply being without some exogenous chemical assistance unendurable. The causes are debated ad nauseam. Was it trauma; physical, psychological, or a combination? Persons who for whatever reason are unable to produces adequate quantities of dopamine or serotonin to feel pleasure will often turn to external substances that promise some relief.

I call it a hole.

This hole is not necessarily caused by trauma (though trauma can deepen it). It is not necessarily caused by poverty (though poverty exacerbates it). It is simply there. Some people are born with it, a prenatal or genetic issue. Some people develop it. Regardless, it is real, and it is permanent for a significant minority of people.

A person’s “drug of choice” often fits the shape of the hole.

• The anxious person chooses depressants (alcohol, heroin).
• The empty person chooses stimulants (cocaine, either smokable or powder) because they provide a false fullness—a temporary feeling of being alive, complete, real.
• The dissociated person chooses psychedelics or dissociatives to break through the wall.
• The person who cannot slow their brain down chooses opiates to finally rest.

The versatility of cannabis is that it shapes itself to fit the needs of the individual. Cannabis is  not for everyone but for those who can tolerate it, it serves to address all the areas listed above.

Mainstream addiction medicine reduces this to “disease model” or “poor choices”. My experience, and the experience of treatment provider I have worked with suggests something far more threatening to the establishment: some people will continue to use drugs because they must, the alternative unendurable.

Part Two: The Continuum

This is something most drug policy discourse refuses to acknowledge, that everyone uses something to get through the day.

The criminal justice system draws an arbitrary line along the continuum of indulgence. It punishes public excesses while ignoring private ones. Street-engaged persons who use substances, whether licit (public alcohol consumption) or illicit (public cannabis smoking), are criminalised. Those able to indulge in the privacy of their own chambers are granted a pass, as long as their excess does not become problematic. The line is not drawn based on science, or even on harm. It is drawn based on stigma, race, and class.

The criminal justice system draws an arbitrary line on the permissible level of indulgence along the continuum. It punishes public excesses while ignoring private ones. Street engaged persons who use substances, either licit (public consumption of alcohol) or illicit (public cannabis smoking) are criminalised while those able to indulge in the privacy of their chamber are granted a pass as long as their excessive use does not become problematic. The line is not drawn based on science, or even on harm. It is drawn based on stigma, race, and class.

In the Caribbean, we have been punishing the poor for cannabis while the rum industry, heavily promoted to the poor, causing far more violence, accidents and death, is celebrated at national festivals as “heritage.”

Part Three: The Inoculation Effect

When I began this work in Saint Lucia in 1989, the United States, either directly through Military Information Support Team’s (MIST) psychological operations (PSYOP) or through the UNODC, was funding “Just Say No” campaigns that depicted all drugs as equally harmful and equally deadly.

The problem was that almost everyone in Saint Lucia knew someone who used cannabis. Cannabis was already integrated into the local pharmacopeia. It is  used as an aid by labourers and farm workers when performing repetitious or onerous tasks. It is used medicinally in “bush” medicine. It was used recreationally and as a sacrament.

When these anti-drug campaigns listed coffee and heroin on the same poster as drugs and inferred similar harms They claimed that “cannabis made a person lazy and unproductive. The population subjected to this campaign messaured the claims against the people they knew, their family, their neighbours, hard-working, diligent, and functional people who also used cannabis. Most concluded the messaging was false.

Which further raised the question: if this information was false, what about the other drugs portrayed? Cannabis and smokable crack cocaine were shown as equally harmful. This led some people in the 1970s/80s to think smoke is smoke, with many experimenting with crack.

This situation was exacerbated by US-led interdiction campaigns that destroyed local cannabis fields. The resulting shortage of cannabis, the substance people trusted, drove some users toward the other smokable substance available, crack cocaine. When crack arrived on the scene, that same population looked at the warnings and assumed they were equally false. When cannabis was scarce, crack filled the void. Some went back to cannabis, but for others, crack filled the hole better. Just another unintended consequence of the war on drugs.

This is not a theory. This was the reality on the ground, and not just in Saint Lucia but throughout the Eastern Caribbean, where US eradication of local cannabis crops was followed by an increase in crack use.

The anti-drug messaging about cannabis was false. By spreading false information, they “inoculated” the population against the truth about crack. The result was catastrophic. Crack use spread rapidly, and with it came harms that were far greater than those of cannabis. The war on drugs created the very epidemic it was supposed to prevent.

Part Four: The Substitution

Almost immediately after crack appeared in Saint Lucia, some users began mixing crack and cannabis to moderate the effects of the crack. In CDARI’s 2007 study of 262 homeless people who smoked crack, 73% also smoked cannabis. Many reported mixing crack and cannabis in a “seasoned spliff”, a practice that was and remains common, with about one-third of those who used crack reporting it.

The reasons for mixing were consistent. Cannabis reduced the negative pharmacological and behavioural effects of crack. It was also free or less expensive, and it helped stretch out the crack, making a limited supply last longer.

The people using crack quickly became aware of the moderating effects of a cannabis/crack mixture. They were titrating their own doses. In Jamaica, ethnographer Melanie Dreher found the same pattern: women mixed crack with cannabis to “calm the demons” released by the “Babylon devil” of crack. The seasoned spliff was viewed as a healing herb, a soothing balm for the psychosis induced by smoking straight crack.

In Brazil, researchers found that the “pitilho” (a cannabis-crack mixture similar to a seasoned spliff) reduced the compulsive re-dosing that makes crack so problematic. People who used both reported improved sleep, appetite, and quality of life.

This is not a fringe finding. The evidence for cannabis substitution is now overwhelming. In a 2009 study from Berkeley, California, medical marijuana users reported substituting cannabis for alcohol (40%), other illicit drugs (26%), and prescription drugs (66%). In Vancouver, longitudinal cohort studies found that people successfully used cannabis to reduce crack use.

Yet the international drug control system, including the UNODC, continues to treat cannabis as a Schedule I drug with no medical value. This is not science. It is ideology.

Part Five: The Anti-Pleasure Police

One of the most insidious arguments in the drug treatment establishment is the claim that substitution therapy must not be pleasurable. The underlying logic is that medicine should be a “bitter pill”, unpleasant to take, to discourage use outside its prescribed purpose. Methadone and buprenorphine are advertised as “satisfying the desire without the pleasure.” But cannabis, a pleasure inducing substance is denied the same status.

Despite the anecdotal evidence that cannabis treatment for crack use works, it is dismissed as “just replacing one drug with another.” The distinction is arbitrary. It is not based on science. It is based on puritanical interpretation of the international drug conventions.

The anti-pleasure police have decided that some substitutions are “medical” while others are “degenerative” The real question is: why are some allowed a methadone maintenance to sustain them but others are denied cannabis as a treatment option for their crack cocaine use?

The answer is political. Methadone, chemically processed, institutionally legitimized by big pharma and distribution controlled by the State. Cannabis is a herb, can be grown in a back yard or a flower pot and is criminalised and highly stigmatised. That is the only difference.

In my professional experience, people who are allowed to use cannabis as a maintenance drug are more stable, less violent, and more functional than people who are forced into abstinence-only programmes especially those mandated by court order.

But the UNODC, the criminal justice system nor the treatment industry can concede this for if they did admit cannabis’ value, they would have to rescind an entire ideological framework based on refer madness.

Part Six: Chronic Maintenance

The most important conclusion of my forty years of work is this:

Some people will never stop using drugs.

They will always need something. It might be methadone. It might be cannabis. It might be prescription amphetamines, which I believe would be a useful substitution for those using illicit and adulterated stimulants such as crack or  methamphetamine, but those who advocate against substitutions that are  pleasurable prevent it. Alcohol is often used as a substitute if other substances are not available. Tobacco in the form of cigarettes, is the only legal product that is promoted globally and yet guaranteed to kill you.

The goal should not be to eliminate the substance. The goal should be to minimize the harms while acknowledging that the need, the hole, is permanent.

This is the uncomfortable truth that the addiction treatment industry refuses to accept. Every rehab promises “recovery.” Every 12-step program promises freedom. Every government campaign promises a drug-free life. But for a significant minority, abstinence is not realistic. They will always need something to get through the day.

We need to stop treating the need for chronic maintenance as a failure. We need to start treating it as what it is, a successful adaptation to a permanent condition.

Part Seven: What This Means for Policy

Decriminalize cannabis.

This is the first step. Saint Lucia is already moving in this direction, carefully, so as not to “attract the eye of the Beast” (the US State Department or the INCB). The Saint Lucia Bureau of Standards, following the lead of the ASTM, formed a cannabis standards committee, which I had the privilege of serving as its inaugural chair. The efforts to adopt standards ensures the quality of the products that will be offered for sale, something lacking under the current regime of decriminalised prohibition. But decriminalization alone is not enough. We need to ensure that people who use medicinal cannabis can access it affordably, legally, and free of adulterants.

Support substitution therapy.

Substitution therapy should not be limited to medically sanctioned opiates. It should include cannabis and, where appropriate, pharmaceutical stimulants. The anti-pleasure police who lobby hard to prohibit pleasurable substitution are not practicing medicine, they are practicing morality.

Acknowledge the pulmonary harms associated with mixing.

While cannabis has been shown to mitigate tobacco-related lung damage when used separately, the practice of mixing cannabis and tobacco, and inhaling deeply, is now being associated with early-onset COPD. Illegality has made safe-use messaging problematic, as education is often seen as permission.

More education is needed on the various harms associated with substances to enable people to make informed decisions.

Stop pretending everyone can be sober.

The addiction treatment industry needs to acknowledge that chronic maintenance is a legitimate outcome. Some people will use cannabis for decades. That is not a failure of moral stature but a survival need, just as daily insulin is to a diabetic.

Admit that the War on Drugs is a war on people.

The War on Drugs is not a public health strategy. It is a war on people whose only crime is trying to get through the day using an illicit substances while the rest of us use alcohol, tobacco, sugar, religion, or fitness for the same outcome. If everyone does something toget through the day then it is our obligation to assist them to do what ever they are doing in the least harmful way possible. All behaviours exist on a continuum from harmless to the extreme with morbidity or mortality following.

Conclusion

The drug treatment establishment has failed to make people drug-free. The international drug control system has failed to make drugs unavailable. The War on Drugs has done nothing but make drugs scarce, and therefore way more profitable to the traffickers than their actual intrinsic value.

It is time to stop pretending. We need to acknowledge that some people have a permanent need for external regulation. If that external regulation takes the form of a substance, we must ensure that people have access to the most beneficial and least harmful options available. We need to stop punishing people and start supporting them.

Harm reduction should not be seen as a stepping stone to abstinence. For some people, harm reduction is the destination.

About the Author

Marcus Day, was the founder and first Director of the Caribbean Drug & Alcohol Research Institute in Saint Lucia. He has been a principal investigator on numerous research projects on people who use drugs, HIV transmission among people who use drugs (particularly non-injecting routes of administration), and the health needs of incarcerated populations in the Caribbean. He has served as a core member of the UN Reference Group on HIV and IDU, Co-Chair of the UNAIDS Regional HIV Prevention Technical Working Group, Board member and Vice Chair of the International Harm Reduction Association, and first Chair of the D37 SLBS National Cannabis Standards Committee. He was awarded a Queen’s Birthday Honour (MBE) for his human rights work.

This paper is dedicated to the people of the streets of Castries—who taught me everything I know.

Keywords: cannabis, harm reduction, crack cocaine, Caribbean, substance substitution, chronic maintenance, drug policy, abstinence, War on Drugs, Saint Lucia, addiction treatment, poly drug use, seasoned spliff, injection drug use, HIV, COPD, anti-pleasure police, drug decriminalization, substitution therapy, drug treatment establishment