Association of State Policies Allowing Medical Cannabis for Opioid Use Disorder With Dispensary Marketing for This Indication

The Role of Medicinal Cannabis as an Emerging Therapy for Opioid Use Disorder

This narrative review explores current insights into the potential use of medicinal cannabis-related products as an emerging therapy for opioid use disorder in the landscape of increasing knowledge about medicinal cannabis-based products, commercialisation and global legalisation. Preclinical studies have provided preliminary insight into the putative neurobiological mechanisms that underpin the potential for medicinal cannabis to be considered a therapeutic in opioid use disorder and addiction. With the progressive legalisation of cannabis in many jurisdictions worldwide, contemporary research has highlighted further evidence that medicinal cannabis may have efficacy in reducing cravings and withdrawal effects, and therefore may be considered as an adjunct or standalone to current medications for opioid use disorder. Despite this potential, the landscape of research in this space draws from a large number of observational studies, with a paucity of rigorous randomised controlled trials to ascertain a true understanding of effect size and safety profile. With current challenges in implementation that arise from political and legal qualms about adopting medicinal cannabis on the background of associated social stigma, significant hurdles remain to be addressed by government, policy-makers, healthcare providers and researchers before medical cannabis can be introduced globally for the treatment of opioid use disorder.

Analysis of social media compliance with cannabis advertising regulations: evidence from recreational dispensaries in Illinois 1-year post-legalization

BACKGROUND

In the USA, an increasing number of states have legalized commercial recreational cannabis markets, allowing a private industry to sell cannabis to those 21 and older at retail locations known as dispensaries. Research on tobacco and alcohol suggests this new industry will use aggressive marketing tactics to attract new users and promote greater intensity of use. Of concern is that cannabis company advertising campaigns may be appealing to youth, promote false or misleading health claims, and disproportionately target low-income and minority communities. In this study, we evaluated recreational cannabis dispensary compliance with advertising regulations on social media in the state of Illinois.

METHODS

Primary data were collected from a census of recreational dispensary Facebook and Twitter business pages during the first year of recreational sales in 2020. A quantitative content analysis was conducted to systematically analyze the data; a codebook that detailed a protocol for classifying posts was developed prior to the analysis using advertising regulations outlined in the Illinois Cannabis Regulation and Tax Act. Violations of advertising regulations were organized into three categories: advertisements that may be appealing to youth (< 21 years old), advertisements that make health claims, and other advertising violations. The data were analyzed cross-sectionally and longitudinally. Additionally, differences in compliance were assessed by dispensary and neighborhood characteristics.

RESULTS

The results of the analysis revealed substantial and persistent non-compliance throughout the entire study period. Overall, nearly one third of posts had at least one violation and approximately one in ten posts met the criteria for appealing to youth or contained health claims. The majority of posts with health claims included health claims that were not qualifying conditions for medical cannabis access in the state of Illinois. No differences in compliance by neighborhood and dispensary characteristics were found.

CONCLUSIONS

The findings from this study suggest that systematic monitoring and enforcement is needed to ensure compliance with advertising regulations.

The impact of cannabis on non-medical opioid use among individuals receiving pharmacotherapies for opioid use disorder: a systematic review and meta-analysis of longitudinal studies

Background: The relationship between cannabis use and the risk of returning to using opioids non-medically during treatment for opioid use disorder (OUD) remains unclear.Objective: We sought to quantify the impact of cannabis use on the risk of non-medical opioid use among people receiving pharmacotherapies for OUD.Methods: A comprehensive search was performed using multiple databases from March 1 to April 5 of 2023. Eligible studies longitudinally assessed the association between cannabis use and non-medical opioid use among people with OUD receiving treatment with buprenorphine, methadone, or naltrexone. We utilized a random-effects model employing the restricted maximum likelihood method. A sensitivity analysis was conducted to understand potential differences between each OUD treatment modality.Results: A total of 10 studies were included in the final meta-analysis. There were 8,367 participants (38% female). The average follow-up time across these studies was 9.7 months (SD = 3.77), ranging from 4 to 15 months. The pharmacotherapies involved were methadone (76.3%) buprenorphine (21.3%), and naltrexone (2.4%). The pooled odds ratio did not indicate that cannabis use significantly influenced non-medical opioid use (OR: 1.00, 95% CI: 0.97-1.04, p = .98). There is evidence of moderate heterogeneity and publication bias.Conclusion: There was no significant association between cannabis use and non-medical opioid use among patients receiving pharmacotherapies for OUD. These findings neither confirm concerns about cannabis increasing non-medical opioid use during MOUD, nor do they endorse its efficacy in decreasing non-medical opioid use with MOUD. This indicates a need for individualized approaches for cannabis use and challenges the requirement of cannabis abstinence to maintain OUD pharmacotherapies.

Health, safety, and socioeconomic impacts of cannabis liberalization laws: An evidence and gap map

Background

Globally, cannabis laws and regulations are rapidly changing. Countries are increasingly permitting access to cannabis under various decriminalization, medicalization, and legalization laws. With strong economic, public health, and social justice incentives driving these domestic cannabis policy reforms, liberalization trends are bound to continue. However, despite a large and growing body of interdisciplinary research addressing the policy-relevant health, safety, and socioeconomic consequences of cannabis liberalization, there is a lack of robust primary and systematic research that comprehensively investigates the consequences of these reforms.

Objectives

This evidence and gap map (EGM) summarizes the empirical evidence on cannabis liberalization policies. Primary objectives were to develop a conceptual framework linking cannabis liberalization policies to relevant outcomes, descriptively summarize the empirical evidence, and identify areas of evidence concentration and gaps.

Search Methods

We comprehensively searched for eligible English-language empirical studies published across 23 academic databases and 11 gray literature sources through August 2020. Additions to the pool of potentially eligible studies from supplemental sources were made through November 2020.

Selection Criteria

The conceptual framework for this EGM draws upon a legal epidemiological perspective highlighting the causal effects of law and policy on population-level outcomes. Eligible interventions include policies that create or expand access to a legal or decriminalized supply of cannabis: comprehensive medical cannabis laws (MCLs), limited medical cannabidiol laws (CBDLs), recreational cannabis laws (RCLs), industrial hemp laws (IHLs), and decriminalization of cultivations laws (DCLs). Eligible outcomes include intermediate responses (i.e., attitudes/behaviors and markets/environments) and longer-term consequences (health, safety, and socioeconomic outcomes) of these laws.

Data Collection and Analysis

Both dual screening and dual data extraction were performed with third person deconfliction. Primary studies were appraised using the Maryland Scientific Methods Scale and systematic reviews were assessed using AMSTAR 2.

Main Results

The EGM includes 447 studies, comprising 438 primary studies and nine systematic reviews. Most research derives from the United States, with little research from other countries. By far, most cannabis liberalization research focuses on the effects of MCLs and RCLs. Studies targeting other laws-including CBDLs, IHLs, and DCLs-are relatively rare. Of the 113 distinct outcomes we documented, cannabis use was the single most frequently investigated. More than half these outcomes were addressed by three or fewer studies, highlighting substantial evidence gaps in the literature. The systematic evidence base is relatively small, comprising just seven completed reviews on cannabis use (3), opioid-related harms (3), and alcohol-related outcomes (1). Moreover, we have limited confidence in the reviews, as five were appraised as minimal quality and two as low quality.

Authors’ Conclusions

More primary and systematic research is needed to better understand the effects of cannabis liberalization laws on longer-term-and arguably more salient-health, safety, and socioeconomic outcomes. Since most research concerns MCLs and RCLs, there is a critical need for research on the societal impacts of industrial hemp production, medical CBD products, and decriminalized cannabis cultivation. Future research should also prioritize understanding the heterogeneous effects of these laws given differences in specific provisions and implementation across jurisdictions.

A national population-based study of cannabis use and correlates among U.S. veterans prescribed opioids in primary care

BACKGROUND

Cannabis is marketed as a treatment for pain. There is limited data on the prevalence of cannabis use and its correlates among Veterans prescribed opioids.

OBJECTIVE

To examine the prevalence and correlates of cannabis use among Veterans prescribed opioids.

DESIGN

Cross-sectional study.

PARTICIPANTS

Veterans with a urine drug test (UDT) from Primary Care 2014-2018, in 50 states, Washington, D.C., and Puerto Rico. A total of 1,182,779 patients were identified with an opioid prescription within 90 days prior to UDT.

MAIN MEASURES

Annual prevalence of cannabis positive UDT by state. We used multivariable logistic regression to assess associations of demographic factors, mental health conditions, substance use disorders, and pain diagnoses with cannabis positive UDT.

RESULTS

Annual prevalence of cannabis positive UDT ranged from 8.5% to 9.7% during the study period, and in 2018 was 18.15% in Washington, D.C. and 10 states with legalized medical and recreational cannabis, 6.1% in Puerto Rico and 25 states with legalized medical cannabis, and 4.5% in non-legal states. Younger age, male sex, being unmarried, and marginal housing were associated with use (p < 0.001). Post-traumatic stress disorder (adjusted odds ratio [AOR] 1.17; 95% confidence interval [CI] 1.13-1.22, p < 0.001), opioid use disorder (AOR 1.14; CI 1.07-1.22, p < 0.001), alcohol use disorder or positive AUDIT-C (AOR 1.34; 95% CI 1.28-1.39, p < 0.001), smoking (AOR 2.58; 95% CI 2.49-2.66, p < 0.001), and other drug use disorders (AOR 1.15; 95% CI 1.03-1.29, p = 0.02) were associated with cannabis use. Positive UDT for amphetamines AOR 1.41; 95% CI 1.26-1.58, p < 0.001), benzodiazepines (AOR 1.41; 95% CI 1.31-1.51, p < 0.001) and cocaine (AOR 2.04; 95% CI 1.75-2.36, p < 0.001) were associated with cannabis positive UDT.

CONCLUSIONS

Cannabis use among Veterans prescribed opioids varied by state and by legalization status. Veterans with PTSD and substance use disorders were more likely to have cannabis positive UDT. Opioid-prescribed Veterans using cannabis may benefit from screening for these conditions, referral to treatment, and attention to opioid safety.

The impact of recreational cannabis markets on motor vehicle accident, suicide, and opioid overdose fatalities

In the U.S., an increasing number of states are legalizing regulated commercial markets for recreational cannabis, which allows private industry to produce, distribute, and sell marijuana to those 21 and older. The health impacts of these markets are not fully understood. Preliminary evidence suggests recreational markets may be associated with increased use among adults, which indicates there may be downstream health impacts on outcomes related to cannabis use. Three causes of death that are linked to cannabis use are motor vehicle accidents, suicide, and opioid overdose. Drawing on data from U.S. death certificates from 2009 to 2019, we conducted a difference-in-differences analysis to estimate the impact of recreational markets on fatalities from motor vehicle accidents, suicide, and opioid overdose in seven states: Colorado, Washington, Oregon, Alaska, Nevada, California, and Massachusetts. States with comprehensive medical cannabis programs with similar pre-trends in deaths were used as comparisons. For each outcome, a pooled estimate was generated with a meta-analysis using random effects models. The results revealed substantial increases in crash fatalities in Colorado, Oregon, Alaska, and California of 16%, 22%, 20%, and 14%, respectively. Based on estimates from all seven states, recreational markets were associated with a 10% increase in motor vehicle accident deaths, on average. This study found no evidence that recreational markets impacted suicides. Most states saw a relative reduction in opioid overdose death that ranged between 3 and 28%. On average, recreational markets were associated with an 11% reduction in opioid overdose fatalities.

Marijuana legalization and opioid deaths

Many states have legalized marijuana over the last two decades, initially for medical purposes and more recently for recreational consumption. Despite prior research, it remains unclear how these policies are related to rates of opioid-involved overdose deaths, which have trended rapidly upwards over time. We examine this question in two ways. First, we replicate and extend previous investigations to show that the prior empirical results are frequently fragile to the choice of specifications and time periods, and probably provide an overly optimistic assessment of the effects of marijuana legalization on opioid deaths. Second, we present new estimates suggesting that legal medical marijuana, particularly when available through retail dispensaries, is associated with higher opioid mortality. The results for recreational marijuana, while less reliable, also indicate that retail sales may be correlated with greater death rates relative to the counterfactual of no legal cannabis. A likely mechanism for these effects is the emergence of illicit fentanyl, which has increased the riskiness of even small positive effects of cannabis legalization on the consumption of opioids.

Clinician Beliefs and Practices Related to Cannabis

Introduction: Medical cannabis (marijuana) use is legal in 33 U.S. states and the District of Columbia. Clinicians can play an important role in helping patients access and weigh potential benefits and risks of medicinal cannabis. Accordingly, this study aimed to assess clinician beliefs and practices related to cannabis. Methods: Data are from 1506 family practice doctors, internists, nurse practitioners, and oncologists who responded to the 2018 DocStyles, a web-based panel survey of clinicians. Questions assessed medicinal uses for and practices related to cannabis and assessed clinicians' knowledge of cannabis legality in their state. Logistic regression was used to assess multivariable correlates of asking about, assessing, and recommending cannabis. Results: Over two-thirds (68.9%) of clinicians surveyed believe that cannabis has medicinal uses and just over a quarter (26.6%) had ever recommended cannabis to a patient. Clinicians who believed cannabis had medicinal uses had 5.9 times the adjusted odds (95% confidence interval 3.9-8.9) of recommending cannabis to patients. Beliefs about conditions for medical cannabis use did not necessarily align with the current scientific evidence. Nearly two-thirds (60.0%) of clinicians surveyed incorrectly reported the legal status of cannabis in their state. Discussion: Findings suggest that while clinicians believe that cannabis has medicinal uses, they may not have a full understanding of the scientific evidence and may not accurately understand their state-based policies for cannabis legalization and use. Given that clinicians are responsible for recommending medicinal cannabis in most states that have legalized it, ongoing education about the health effects of cannabis is warranted.

Randomised, pragmatic, waitlist controlled trial of cannabis added to prescription opioid support on opioid dose reduction and pain in adults with chronic non-cancer pain: study protocol

INTRODUCTION

Chronic, non-cancer pain impacts approximately 50 million adults in the USA (20%), approximately 25% of whom receive chronic prescription opioids for pain despite limited empirical efficacy data and strong dose-related risk for opioid use disorder and opioid overdose. Also despite lack of efficacy data, there are many reports of people using cannabis products to manage chronic pain and replace or reduce chronic opioids. Here we describe the protocol for a randomised trial of the effect of cannabis, when added to a behavioural pain management and prescription opioid taper support programme, on opioid utilisation, pain intensity and pain interference.

METHODS

This is a pragmatic, single-blind, randomised, wait-list controlled trial that aims to enrol 250 adults taking prescription opioids at stable doses of ≥25 morphine milligram equivalents per day for chronic non-cancer pain who express interest in using cannabis to reduce their pain, their opioid dose or both. All participants will be offered a weekly, 24-session Prescription Opioid Taper Support group behavioural pain management intervention. Participants will be randomly assigned in 1:1 ratio to use cannabis products, primarily from commercial cannabis dispensaries or to abstain from cannabis use for 6 months. Coprimary outcomes are change in prescription monitoring programme-verified opioid dose and change in Pain, Enjoyment, General Activity scale scores. Secondary outcomes include quality of life, depression, anxiety, self-reported opioid dose and opioid and cannabis use disorder symptoms. All other outcomes will be exploratory. We will record adverse events.

ETHICS AND DISSEMINATION

This study has ethical approval by the Massachusetts General Brigham Institutional Review Board (#2021P000871). Results will be published in peer-reviewed journals and presented at national conferences.

TRIAL REGISTRATION NUMBER

NCT04827992.

Association between Participation in Counseling and Retention in a Buprenorphine-Assisted Treatment Program for People Experiencing Homelessness with Opioid Use Disorder

The opioid epidemic is a public health crisis that disproportionately affects our unsheltered neighbors. Because medication-assisted treatment (MAT) is effective for preventing deaths from drug overdose and retention is associated with better health outcomes, there is a clear need for more research on factors impacting retention in care. This retrospective cohort analysis examines the relationship between attendance in counseling and retention on buprenorphine for three or more months for individuals experiencing homelessness being treated at a Federally Qualified Health Center (FQHC) and Public Health Service Act §330(h) Health Care for the Homeless Program grantee in San Diego County, California. The cohort included 306 adults experiencing homelessness who had at least one prescription for buprenorphine and participated in a MAT program between 2017 and 2019. The sample included 64.4% men, almost exclusively white, and 35% lived in a place not meant for human habitation. Of the sample, 97 patients were retained at 3 months and 209 were not. Results from a logistic regression model showed that counseling appointments were positively associated with retention at three months (OR = 1.57, p < 0.001). Findings from this study inform future MAT program design components for people experiencing homelessness.

Comparing older nonmedical and medical cannabis users: health-related characteristics, cannabis use patterns, and cannabis sources

Background: US epidemiologic data show that nearly one in 10 individuals aged 50+ report past-year cannabis use, and nearly one in five users report medical use. However, research on older cannabis users, especially medical cannabis users, is scant.Objectives: We examined medical and nonmedical cannabis users aged 50+ on health-related characteristics, cannabis use patterns, and cannabis sources. Hypotheses were that compared to nonmedical users, medical users are more likely to have physical and mental health problems, use healthcare services, discuss their drug use with a healthcare professional, use cannabis more frequently, and purchase cannabis from a medical dispensary and other sources rather than obtain it as a gift, share someone else's, or use other means.Methods: We used 2018 and 2019 National Survey on Drug Use and Health data (N = 17,685 aged 50+; male = 8,030; female = 9,655). Hypotheses were tested using logistic regression analysis.Results: The past-year cannabis use rate was 8.9%. Of past-year users, 18.5% reported medical use. Compared to nonmedical use, medical use was associated with lower odds of alcohol use disorder but higher odds of discussing drug use with a healthcare professional (AOR = 4.18, 95% CI = 2.53-6.89), high-frequency use (e.g., AOR = 2.56, 95% CI = 1.35-4.86 for 200-365 days), and purchase at a medical cannabis dispensary (AOR = 4.38, 95% CI = 2.47-7.76).Conclusion: Medical and nonmedical users did not differ on physical and most behavioral health indicators. Most obtained cannabis from private/informal sources. Some medical users are likely to self-treat without healthcare professional consultation. Healthcare professionals should engage older adults in discussions of cannabis use and behavioral health needs.

Evaluation of State Cannabis Laws and Rates of Self-harm and Assault

Importance

State cannabis laws are changing rapidly. Research is inconclusive about their association with rates of self-harm and assault. Existing studies have not considered variations in cannabis commercialization across states over time.

Objective

To evaluate the association of state medical and recreational cannabis laws with self-harm and assault, overall and by age and sex, while considering varying degrees of commercialization.

Design, Setting, and Participants

Using a cohort design with panel fixed-effects analysis, within-state changes in claims for self-harm and assault injuries before and after changes in cannabis laws were quantified in all 50 US states and the District of Columbia. Comprehensive claims data on commercial and Medicare Advantage health plan beneficiaries from January 1, 2003, to December 31, 2017, grouped by state and month, were evaluated. Data analysis was conducted from January 31, 2020, to January 21, 2021.

Exposures

Categorical variable that indexed the degree of cannabis legalization in each state and month based on law type (medical or recreational) and operational status of dispensaries (commercialization).

Main Outcomes and Measures

Claims for self-harm and assault injuries based on International Classification of Diseases codes.

Results

The analysis included 75 395 344 beneficiaries (mean [SD] age, 47 [22] years; 50% female; and median follow-up, 17 months [interquartile range, 8-36 months]). During the study period, 29 states permitted use of medical cannabis and 11 permitted recreational cannabis. Point estimates for populationwide rates of self-harm and assault injuries were higher in states legalizing recreational cannabis compared with states with no cannabis laws, but these results were not statistically significant (adjusted rate ratio [aRR] assault, recreational dispensaries: 1.27; 95% CI, 0.79-2.03;self-harm, recreational dispensaries aRR: 1.15; 95% CI, 0.89-1.50). Results varied by age and sex with no associations found except for states with recreational policies and self-harm among males younger than 40 years (aRR <21 years, recreational without dispensaries: 1.70; 95% CI, 1.11-2.61; aRR aged 21-39 years, recreational dispensaries: 1.46; 95% CI, 1.01-2.12). Medical cannabis was generally not associated with self-harm or assault injuries populationwide or among age and sex subgroups.

Conclusions and Relevance

Recreational cannabis legalization appears to be associated with relative increases in rates of claims for self-harm among male health plan beneficiaries younger than 40 years. There was no association between cannabis legalization and self-harm or assault, for any other age and sex group or for medical cannabis. States that legalize but still constrain commercialization may be better positioned to protect younger male populations from unintended harms.

Human Laboratory Models of Cannabis Use: Applications for Clinical and Translational Psychiatry Research

Cannabis is increasingly used by individuals with mental health diagnoses and often purported to treat anxiety and various other psychiatric symptoms. Yet support for using cannabis as a psychiatric treatment is currently limited by a lack of evidence from rigorous placebo-controlled studies. While regulatory hurdles and other barriers make clinical trials of cannabis challenging to conduct, addiction researchers have decades of experience studying cannabis use in human laboratory models. These include methods to control cannabis administration, to delineate clinical and mechanistic aspects of cannabis use, and to evaluate potential treatment applications for cannabis and its constituents. In this paper, we review these human laboratory procedures and describe how each can be applied to study cannabis use in patients with psychiatric disorders. Because anxiety disorders are among the most common psychiatric illnesses affecting American adults, and anxiety relief is also the most commonly-reported reason for medicinal cannabis use, we focus particularly on applying human laboratory models to study cannabis effects in individuals with anxiety and related disorders. Finally, we discuss how these methods can be integrated to study cannabis effects in other psychiatric conditions and guide future research in this area.

Clinical Conditions and Prescription Drug Utilization among Early Medical Marijuana Registrants in Florida

Initial legalization of medical marijuana (MM) in Florida required providers to submit initial and follow-up treatment plan forms to the University of Florida to support research on MM safety and efficacy. This study retrospectively analyzed all treatment plan forms submitted between program inception (August 2016) through July 2017 and describes early Florida MM registrants by clinical conditions and prescription drug utilization. Among 7,548 unique treatment plans, the initial visit was characterized by registrants who were mostly white (83.7%), 52.3 (SD 16.4) years of age on average, and who were assessed by the provider as at least moderately ill (79.6%). Musculoskeletal and spasticity-related conditions (44.8%), chronic pain (41.9%), and mental health disorders (17.0%) were the most frequent medical complaints for seeking MM treatment with more than one condition per patient possible. One in four (25.9%) patients reported use of prescription opioids and over one-fifth of patients frequently utilized at least one psychotropic medication as well as cardiovascular agents. There were 2,075 unique follow-up plans available which were mostly characterized by clinical improvement and reported reductions in utilization of some drug classes. Further research is needed to guide clinicians on the risks and benefits of MM used concomitantly with prescription drugs.