Access to unregulated community-based models of cannabis distribution among people who use unregulated drugs in Canada

Background: The toxic drug emergency in North America has garnered interest in the strategic use of cannabis to reduce harms associated with higher-risk drugs. However, in British Columbia, Canada, licit sources of cannabis may be inaccessible among marginalized people who use unregulated drugs (PWUD). Unregulated community-based cannabis distribution models could be better suited to reach PWUD seeking cannabis for harm reduction purposes. This thesis sought to 1) synthesize the literature describing the social inclusion-enhancing effects of accessing community-based cannabis distribution models, 2) characterize PWUD who access cannabis substitution programs (CSPs), and 3) evaluate the relationship between accessing unregulated dispensaries as a primary cannabis source and nonfatal overdose. Methods: A narrative literature review was conducted to identify the social effects of accessing community-based cannabis distribution models. Data for the two empirical studies were derived from three prospective cohorts of PWUD in Vancouver. Study 1 employed logistic regression modeling to analyze the relationship between accessing CSPs and demographic, socio-structural, health, and substance use-related factors. Study 2 used generalized estimating equations (GEE) adjusted for potential confounders to estimate the longitudinal relationship between accessing dispensaries as a primary cannabis source and nonfatal overdose. Results: Among the 15 articles included in the review, several themes related to social inclusion emerged. Study 1 (November 2019 - July 2021), observed 412 PWUD, 22.8% reporting CSP access. In multivariable logistic regression analysis, participants accessing CSPs were significantly more likely to be using cannabis for pain, sleep, and reducing opioid withdrawal symptoms, and more likely to report extreme pain and daily injection drug use. Study 2 (June 2016 - March 2020), followed 751 PWUD reporting dispensaries as their primary cannabis source. In multivariable GEE analysis, reporting dispensaries as a primary source was associated with reduced likelihood of nonfatal overdose. Conclusions: These findings highlight the connection between social determinants of health, such as stigma, and inequitable cannabis access among marginalized PWUD. These results demonstrate how community-based cannabis distribution models reach individuals facing complex challenges to obtaining licit cannabis, and that low-barrier access is linked to protective effects on drug-related harms.