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Bleyer A, Barnes B, Finn K. United States marijuana legalization and opioid mortality trends before and during the first year of the COVID-19 pandemic. J Opioid Manag 2024; 20:119-132. [PMID: 38700393 DOI: 10.5055/jom.0829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
BACKGROUND To determine if marijuana legalization was associated with reduced opioid mortality. STUDY DESIGN The United States (US) opioid mortality trend during the 2010-2019 decade was compared in states and District of Columbia (jurisdictions) that had implemented marijuana legalization with states that had not. Acceleration of opioid mortality during 2020, the first year of the coronavirus disease 2019 (COVID-19) pandemic, was also compared in recreational and medicinal-only legalizing jurisdictions. METHODS Joinpoint methodology was applied to the Centers for Disease Control and Prevention WONDER data. Trends in legalizing jurisdictions were cumulative aggregates. RESULTS The overall opioid and fentanyl death rates and the percentage of opioid deaths due to fentanyl increased more during 2010-2019 in jurisdictions that legalized marijuana than in those that did not (pairwise comparison p = 0.007, 0.05, and 0.006, respectively). By 2019, the all-opioid and fentanyl death rates were 44 and 50 percent greater in the legalizing than in the nonlegalizing jurisdictions, respectively. When the COVID-19 pandemic hit in 2020, jurisdictions that implemented recreational marijuana legalization before 2019 had significantly greater increases in both overall opioid and fentanyl death rates than jurisdictions with medicinal-only legalization. For all-opioids, the mean (95 percent confidence interval) 2019-to-2020 increases were 46.5 percent (36.6, 56.3 percent) and 29.1 percent (20.2, 37.9 percent), respectively (p = 0.02). For fentanyl, they were 115.6 percent (80.2, 151.6 percent) and 55.4 percent (31.6, 79.2 percent), respectively (p = 0.01). CONCLUSIONS During the past decade, marijuana legalization in the US was associated at the jurisdiction level with a greater acceleration in opioid death rate. An even greater increase in opioid mortality occurred in recreational-legalizing jurisdictions with the onset of the COVID-19 pandemic. Marijuana legalization is correlated with worsening of the US opioid epidemic.
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Affiliation(s)
- Archie Bleyer
- Oregon Health and Science University, Portland, Oregon; University of Texas McGovern Medical School, Houston, Texas. ORCID: https://orcid.org/0000-0001-7738-5146
| | - Brian Barnes
- St. Charles Healthcare System, Bend, Oregon; PhD Candidate, Integral and Transpersonal Psychology, California Institute of Integral Studies, San Francisco, California
| | - Kenneth Finn
- Springs Rehabilitation, Colorado Springs, Colorado
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Jeddi HM, Busse JW, Sadeghirad B, Levine M, Zoratti MJ, Wang L, Noori A, Couban RJ, Tarride JE. Cannabis for medical use versus opioids for chronic non-cancer pain: a systematic review and network meta-analysis of randomised clinical trials. BMJ Open 2024; 14:e068182. [PMID: 38171632 PMCID: PMC10773353 DOI: 10.1136/bmjopen-2022-068182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 11/27/2023] [Indexed: 01/05/2024] Open
Abstract
OBJECTIVE The objective of this study is to evaluate the comparative benefits and harms of opioids and cannabis for medical use for chronic non-cancer pain. DESIGN Systematic review and network meta-analysis. DATA SOURCES EMBASE, MEDLINE, CINAHL, AMED, PsycINFO, PubMed, Web of Science, Cannabis-Med, Epistemonikos and the Cochrane Library (CENTRAL) from inception to March 2021. STUDY SELECTION Randomised trials comparing any type of cannabis for medical use or opioids, against each other or placebo, with patient follow-up ≥4 weeks. DATA EXTRACTION AND SYNTHESIS Paired reviewers independently extracted data. We used Bayesian random-effects network meta-analyses to summarise the evidence and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach to evaluate the certainty of evidence and communicate our findings. RESULTS Ninety trials involving 22 028 patients were eligible for review, among which the length of follow-up ranged from 28 to 180 days. Moderate certainty evidence showed that opioids provide small improvements in pain, physical functioning and sleep quality versus placebo; low to moderate certainty evidence supported similar effects for cannabis versus placebo. Neither was more effective than placebo for role, social or emotional functioning (all high to moderate certainty evidence). Moderate certainty evidence showed there is probably little to no difference between cannabis for medical use and opioids for physical functioning (weighted mean difference (WMD) 0.47 on the 100-point 36-item Short Form Survey physical component summary score, 95% credible interval (CrI) -1.97 to 2.99), and cannabis resulted in fewer discontinuations due to adverse events versus opioids (OR 0.55, 95% CrI 0.36 to 0.83). Low certainty evidence suggested little to no difference between cannabis and opioids for pain relief (WMD 0.23 cm on a 10 cm Visual Analogue Scale (VAS), 95% CrI -0.06 to 0.53) or sleep quality (WMD 0.49 mm on a 100 mm VAS, 95% CrI -4.72 to 5.59). CONCLUSIONS Cannabis for medical use may be similarly effective and result in fewer discontinuations than opioids for chronic non-cancer pain. PROSPERO REGISTRATION NUMBER CRD42020185184.
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Affiliation(s)
- Haron M Jeddi
- Department of Health Research Methods, Evidence, and Impact (HEI), Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Ontario, Canada
| | - Jason W Busse
- Department of Health Research Methods, Evidence, and Impact (HEI), Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Ontario, Canada
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
- Michael G. DeGroote Institute of Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
| | - Behnam Sadeghirad
- Department of Health Research Methods, Evidence, and Impact (HEI), Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Ontario, Canada
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
- Michael G. DeGroote Institute of Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
| | - Mitchell Levine
- Department of Health Research Methods, Evidence, and Impact (HEI), Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Division of Clinical Pharmacology and Toxicology, St. Joseph's Healthcare, Hamilton, Ontario, Canada
- Center for Health Economics and Policy Analysis (CHEPA), McMaster University, Hamilton, Ontario, Canada
- Programs for Assessment of Technology in Health (PATH), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Michael J Zoratti
- Department of Health Research Methods, Evidence, and Impact (HEI), Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Ontario, Canada
| | - Li Wang
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
- Michael G. DeGroote Institute of Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
| | - Atefeh Noori
- Department of Health Research Methods, Evidence, and Impact (HEI), Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Ontario, Canada
- Hand Program, Division of Plastic, Reconstructive and Aesthetic Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Rachel J Couban
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Jean-Eric Tarride
- Department of Health Research Methods, Evidence, and Impact (HEI), Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Ontario, Canada
- Center for Health Economics and Policy Analysis (CHEPA), McMaster University, Hamilton, Ontario, Canada
- Programs for Assessment of Technology in Health (PATH), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare, Hamilton, Ontario, Canada
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Williams AR, Mauro CM, Feng T, Waples J, Martins SS, Haney M. Adult Medical Cannabinoid Use and Changes in Prescription Controlled Substance Use. Cannabis Cannabinoid Res 2023; 8:933-941. [PMID: 35486854 PMCID: PMC10589493 DOI: 10.1089/can.2021.0212] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Introduction: Nonopioid-based strategies for managing chronic noncancer pain are needed to help reduce overdose deaths. Although lab studies and population-level data suggest that cannabinoids could provide opioid-sparing effects, among medical cannabis participants they may also impact overdose risk by modifying other controlled substance use such as sedative hypnotics. However, no study has combined observational data at the individual level to empirically address interactions between the use of cannabinoids and prescribed controlled substances. Methods: Electronic health records, including prescription drug monitoring program data, from a large multisite medical cannabis program in New York State were abstracted for all participants with noncancer pain and recently prescribed noncannabinoid controlled substances who completed a new intake visit from April 15, 2018-April 14, 2019 and who remained actively in treatment for >180 days. Participants were partitioned into two samples: those with recent opioid use and those with active opioid use and co-use of sedative hypnotics. A patient-month level analysis assessed total average equivalent milligrams by class of drug (i.e., cannabinoid distinguishing tetrahydrocannabinol [THC] vs. cannabidiol [CBD], opioids, and sedative-hypnotics) received as a time-varying outcome measure across each 30-day "month" period postintake for at least 6 months for all participants. Results: Sample 1 of 285 opioid users were 61.1 years of age (±13.5), 57.5% female, and using an average of 49.7 (±98.5) morphine equivalents daily at intake. Unadjusted analyses found a modest decline in morphine equivalents to 43.9 mg (±94.1 mg) from 49.7 (±98.5) in month 1 (p=0.047) while receiving relatively low doses of THC (2.93 mg/day) and CBD (2.15 mg/day). Sample 2 of 95 opioid and sedative-hypnotic users were 60.9 years of age (±13.1), 63.2% female, and using an average of 86.6 (±136.2) morphine equivalents daily, and an average of 4.3 (±5.6) lorazepam equivalents. Unadjusted analyses did not find significant changes in either morphine equivalents (p=0.81) or lorazepam equivalents (p=0.980), and patients similarly received relatively low doses of THC (2.32 mg/day) and CBD (2.24 mg/day). Conclusions: Findings demonstrated minimal to no change in either opioids or sedative hypnotics over the 6 months of medical cannabis use but may be limited by low retention rates, external generalizability, and an inability to account for nonprescribed substance use.
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Affiliation(s)
- Arthur Robin Williams
- Department of Psychiatry, New York State Psychiatric Institute, Columbia University Medical Center, New York, New York, USA
- Research Foundation for Mental Hygiene, New York, New York, USA
| | - Christine M. Mauro
- Department of Biostatistics, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Tianshu Feng
- Research Foundation for Mental Hygiene, New York, New York, USA
| | - Josef Waples
- City University of New York School of Professional Studies, New York, New York, USA
| | - Silvia S. Martins
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Margaret Haney
- Research Foundation for Mental Hygiene, New York, New York, USA
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Davis MP, Case AA, Cyr C. Do We Have Structure, Process and Outcomes to Support Cannabis as Supportive Therapy in Cancer? Am J Hosp Palliat Care 2023; 40:341-350. [PMID: 35532011 DOI: 10.1177/10499091221101561] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Cannabis is becoming more popular and more available in the United States. It has been approved for use by multiple states for various conditions and several states now allow recreational cannabis. We explore the structure of cannabis distribution, the process of acquisition, outcomes, and the safety of cannabis in the United States.
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Affiliation(s)
- Mellar P Davis
- 2780Geisinger Commonwealth School of Medicine, Danville, PA, USA
| | - Amy A Case
- Department of Medicine, Department of Supportive and Palliative Care, 2074Roswell Park Comprehensive Cancer Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Claude Cyr
- Supportive and Palliative Care Division, 12367McGill University Health Center, Montreal, QC, Canada
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Keyhani S, Leonard S, Byers AL, Zaman T, Krebs E, Austin PC, Moss-Vazquez T, Austin C, Sandbrink F, Bravata DM. Association of a Positive Drug Screening for Cannabis With Mortality and Hospital Visits Among Veterans Affairs Enrollees Prescribed Opioids. JAMA Netw Open 2022; 5:e2247201. [PMID: 36525274 PMCID: PMC9856228 DOI: 10.1001/jamanetworkopen.2022.47201] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
IMPORTANCE Cannabis has been proposed as a therapeutic with potential opioid-sparing properties in chronic pain, and its use could theoretically be associated with decreased amounts of opioids used and decreased risk of mortality among individuals prescribed opioids. OBJECTIVE To examine the risks associated with cannabis use among adults prescribed opioid analgesic medications. DESIGN, SETTING, AND PARTICIPANTS This cohort study was conducted among individuals aged 18 years and older who had urine drug screening in 2014 to 2019 and received any prescription opioid in the prior 90 days or long-term opioid therapy (LTOT), defined as more than 84 days of the prior 90 days, through the Veterans Affairs health system. Data were analyzed from November 2020 through March 2022. EXPOSURES Biologically verified cannabis use from a urine drug screen. MAIN OUTCOMES AND MEASURES The main outcomes were 90-day and 180-day all-cause mortality. A composite outcome of all-cause emergency department (ED) visits, all-cause hospitalization, or all-cause mortality was a secondary outcome. Weights based on the propensity score were used to reduce confounding, and hazard ratios [HRs] were estimated using Cox proportional hazards regression models. Analyses were conducted among the overall sample of patients who received any prescription opioid in the prior 90 days and were repeated among those who received LTOT. Analyses were repeated among adults aged 65 years and older. RESULTS Among 297 620 adults treated with opioids, 30 514 individuals used cannabis (mean [SE] age, 57.8 [10.5] years; 28 784 [94.3%] men) and 267 106 adults did not (mean [SE] age, 62.3 [12.3] years; P < .001; 247 684 [92.7%] men; P < .001). Among all patients, cannabis use was not associated with increased all-cause mortality at 90 days (HR, 1.07; 95% CI, 0.92-1.22) or 180 days (HR, 1.00; 95% CI, 0.90-1.10) but was associated with an increased hazard of the composite outcome at 90 days (HR, 1.05; 95% CI, 1.01-1.07) and 180 days (HR, 1.04; 95% CI, 1.01-1.06). Among 181 096 adults receiving LTOT, cannabis use was not associated with increased risk of all-cause mortality at 90 or 180 days but was associated with an increased hazard of the composite outcome at 90 days (HR, 1.05; 95% CI, 1.02-1.09) and 180 days (HR, 1.05; 95% CI, 1.02-1.09). Among 77 791 adults aged 65 years and older receiving LTOT, cannabis use was associated with increased 90-day mortality (HR, 1.55; 95% CI, 1.17-2.04). CONCLUSIONS AND RELEVANCE This study found that cannabis use among adults receiving opioid analgesic medications was not associated with any change in mortality risk but was associated with a small increased risk of adverse outcomes and that short-term risks were higher among older adults receiving LTOT.
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Affiliation(s)
- Salomeh Keyhani
- Department of Medicine, University of California, San Francisco
- San Francisco VA Medical Center, San Francisco, California
| | - Samuel Leonard
- Northern California Institute for Research and Education, San Francisco
| | - Amy L. Byers
- Department of Medicine, University of California, San Francisco
- San Francisco VA Medical Center, San Francisco, California
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco
| | - Tauheed Zaman
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco
- Addiction Recovery and Treatments Services, San Francisco VA Health Care System, San Francisco, California
| | - Erin Krebs
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota Medical School, Minneapolis
| | - Peter C. Austin
- Institute of Health Policy, Management and Evaluation, University of Toronto
| | | | - Charles Austin
- Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
| | - Friedhelm Sandbrink
- National Pain Management, Opioid Safety and Prescription Drug Monitoring Program, Veterans Health Administration, Washington, District of Columbia
- Department of Neurology, George Washington University, Washington District of Columbia
| | - Dawn M. Bravata
- Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
- Departments of Medicine and Neurology, Indiana University School of Medicine, Indianapolis
- Regenstreif Institute, Indianapolis Indiana
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