Effects of Legal Access to Cannabis on Scheduled II-V Drug Prescriptions

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.

Systematic combinations of major cannabinoid and terpene contents in Cannabis flower and patient outcomes: a proof-of-concept assessment of the Vigil Index of Cannabis Chemovars

BACKGROUND

Little is known about the frequency with which different combinations of phytochemicals (chemovars) arise in Cannabis flower or whether common chemovars are associated with distinct pharmacodynamics and patient health outcomes. This study created a clinically relevant, user-friendly, scalable chemovar indexing system summarizing primary cannabinoid and terpene contents and tested whether the most frequently consumed chemovars differ in their treatment effectiveness and experienced side effects.

METHODS

Between 09/10/2016 and 03/11/2021, 204 people used the freely available, educational mobile software application, Releaf App, to record 6309 real-time consumption sessions using 633 distinct Cannabis flower products, unique at the user level, with terpene and cannabinoid potency information. The indexing system is based on retrospective data analysis of the products' primary and secondary terpene contents and tetrahydrocannabinol (THC) and cannabidiol (CBD) potencies and yielded a total of 478 distinct chemovars. Analyses of covariances (ANCOVAs) were used to compare symptom levels and side effects experienced across the five most common chemovars before and after cannabis consumption for app users overall and for those treating chronic pain and depression or anxiety.

RESULTS

Examination of the five most frequently consumed chemovars showed significant differences in symptom treatment effectiveness for chronic pain and for depression and anxiety (ps < .001). While the effects varied in magnitude, the five chemovars were effective across conditions except for MC61 (mercene .01-0.49%/beta-caryophyllene .01 to 0.49%/THC 20-25%/CBD 0.01-1.0%), which exacerbated feelings of anxiety or depression. The chemovars also differed in their association with experiencing positive, negative, and context-specific side effects, with two chemovars, MC61 and MC62 (mercene .01-0.49%/beta-caryophyllene .01-0.49%/THC 20-25%/CBD 1-5%), generating two to three fewer positive side effects and as much as one more negative and two more context-specific side effects than the other three chemovars.

CONCLUSIONS

The findings provide "proof-of-concept" that a simple, yet comprehensive chemovar indexing system can be used to identify systematic differences in clinically relevant patient health outcomes and other common experiences across Cannabis flower products, irrespective of the product's commercial or strain name. This study was limited by self-selection into cannabis and app use and a lack of user-specific information. Further research using this chemovar indexing system should assess how distinct combinations of phytochemicals interact with user-level characteristics to produce general and individualized Cannabis consumption experiences and health outcomes, ideally using randomized methods to assess differences in effects across chemovars.

The Impact of Cannabis Decriminalization and Legalization on Road Safety Outcomes: A Systematic Review

INTRODUCTION

There is substantial debate concerning the impact of cannabis decriminalization and legalization on road safety outcomes.

METHODS

Seven databases were systematically searched: Embase, MEDLINE, and PsycINFO through Ovid as well as Web of Science Core Collection, SafetyLit, Criminal Justice Database (ProQuest), and Transport Research International Documentation (from inception to June 16, 2021). Eligible primary studies examined group-level cannabis decriminalization or legalization and a road safety outcome in any population.

RESULTS

A total of 65 reports of 64 observational studies were eligible, including 39 that applied a quasi-experimental design. Studies examined recreational cannabis legalization (n=50), medical cannabis legalization (n=22), and cannabis decriminalization (n=5). All studies except 1 used data from the U.S. or Canada. Studies found mixed impacts of legalization on attitudes, beliefs, and self-reported driving under the influence. Medical legalization, recreational legalization, and decriminalization were associated with increases in positive cannabis tests among drivers. Few studies examined impacts on alcohol or other drug use, although findings suggested a decrease in positive alcohol tests among drivers associated with medical legalization. Medical legalization was associated with reductions in fatal motor-vehicle collisions, whereas recreational legalization was conversely associated with increases in fatal collisions.

DISCUSSION

Increased cannabis positivity may reflect changes in cannabis use; however, it does not in itself indicate increased impaired driving. Subgroups impacted by medical and recreational legalization, respectively, likely explain opposing findings for fatal collisions. More research is needed concerning cannabis decriminalization; the impacts of decriminalization and legalization on nonfatal injuries, alcohol and other drugs; and the mechanisms by which legalization impacts road safety outcomes.

U.S. cannabis laws projected to cost generic and brand pharmaceutical firms billions

Legalization of cannabis by U.S. states is likely increasing the use of cannabis as an alternative to conventional pharmaceutical drugs. We examined how cannabis legalization between 1996 and 2019 affected stock market returns for listed generic and brand pharmaceutical companies and found that returns were 1.5-2% lower at 10 days after legalization. Returns decreased in response to both medical and recreational legalization, for both generic and brand drugmakers. Investors anticipate a single legalization event to reduce drugmaker annual sales by $3B on average.

The Effectiveness and Safety of Medical Cannabis for Treating Cancer Related Symptoms in Oncology Patients

The use of medical cannabis (MC) to treat cancer-related symptoms is rising. However, there is a lack of long-term trials to assess the benefits and safety of MC treatment in this population. In this work, we followed up prospectively and longitudinally on the effectiveness and safety of MC treatment. Oncology patients reported on multiple symptoms before and after MC treatment initiation at one-, three-, and 6-month follow-ups. Oncologists reported on the patients' disease characteristics. Intention-to-treat models were used to assess changes in outcomes from baseline. MC treatment was initiated by 324 patients and 212, 158 and 126 reported at follow-ups. Most outcome measures improved significantly during MC treatment for most patients (p < 0.005). Specifically, at 6 months, total cancer symptoms burden declined from baseline by a median of 18%, from 122 (82-157) at baseline to 89 (45-138) at endpoint (-18.98; 95%CI= -26.95 to -11.00; p < 0.001). Reported adverse effects were common but mostly non-serious and remained stable during MC treatment. The results of this study suggest that MC treatment is generally safe for oncology patients and can potentially reduce the burden of associated symptoms with no serious MC-related adverse effects.

The Effects of Consuming <b><i>Cannabis</i></b> Flower for Treatment of Fatigue

<b><i>Objectives:</i></b> We measure for the first time how commercially available <i>Cannabis</i> flower products affect feelings of fatigue. <b><i>Methods:</i></b> A total of 1,224 people recorded 3,922 <i>Cannabis</i> flower self-administration sessions between June 6, 2016, and August 7, 2019, using the Releaf App. Usage sessions included real-time subjective changes in fatigue intensity levels prior to and following <i>Cannabis</i> consumption, <i>Cannabis</i> flower characteristics (labeled phenotype, cannabinoid potency levels), combustion method, and any potential experienced side effects. <b><i>Results:</i></b> On average, 91.94% of people experienced decreased fatigue following consumption with an average symptom intensity reduction of 3.48 points on a 0–10 visual analog scale (SD = 2.70, <i>d</i> = 1.60, <i>p</i> &#x3c; 0.001). While labeled plant phenotypes (“<i>C. indica</i>,” “<i>C. sativa</i>,” or “hybrid”) did not differ in symptom relief, people that used joints to combust the flower reported greater symptom relief than pipe or vaporizer users. Across cannabinoid levels, tetrahydrocannabinol, and cannabidiol levels were generally not associated with changes in symptom intensity levels. <i>Cannabis</i> use was associated with several negative side effects that correspond to increased feelings of fatigue (e.g., feeling unmotivated, couch-locked) among a minority of users (&#x3c;24% of users), with slightly more users (up to 37%) experiencing a positive side effect that corresponds to increased energy (e.g., feeling active, energetic, frisky, or productive). <b><i>Conclusions:</i></b> The findings suggest that the majority of patients experience decreased fatigue from consumption of <i>Cannabis</i> flower consumed in vivo, although the magnitude of the effect and extent of side effects experienced likely vary with individuals’ metabolic states and the synergistic chemotypic properties of the plant.

Chronic Pain Clinical and Prescriptive Practices in the Cannabis Era

BACKGROUND

To explore how health care providers in the United States are adapting clinical recommendations and prescriptive practices in response to patient use of medical cannabis (MC) for chronic pain symptoms.

DESIGN

Literature searches queried MeSH/Subject terms "chronic pain," "clinician," "cannabis," and Boolean text words "practice" and "analgesics" in EBSCOHost, EMBASE, PubMed, and Scopus, published 2010-2021 in the United States. Twenty-one primary, peer-reviewed studies met criteria.

METHODS

Studies are synthesized under major headings: recommending MC for chronic pain; MC and prescription opioids; and harm reduction of MC.

RESULTS

MC is increasingly utilized by patients for chronic pain symptoms. Clinical recommendations for or against MC are influenced by scopes of practice, state or federal laws, institutional policies, education, potential patient harm (or indirect harm of others), and perceived confidence. Epidemiologic and cohort studies show downward trajectories of opioid prescribing and consumption in states with legal cannabis. However, clinicians' recommendations and prescription practices are nonuniform. Impacts of cannabis laws are clear between nongovernmental and governmental institutions. Strategies addressing MC and opioid use include frequent visits, and, to reduce harm, suggesting alternative therapies and treating substance use disorders.

CONCLUSIONS

MC use for chronic pain is increasing with cannabis legalization. Provider practices are heterogenous, demonstrating a balance of treating chronic pain using available evidence, while being aware of potential harms associated with MC and opioids.

Medical Cannabis for Headache Pain: a Primer for Clinicians

PURPOSE OF REVIEW

Public acceptance of Cannabis sativa L. (cannabis) as a therapeutic option grows despite lags in both research and clinician familiarity. Cannabis-whether as a medical, recreational, or illicit substance-is and has been commonly used by patients. With ongoing decriminalization efforts, decreased perception of harms, and increased use of cannabis in the treatment of symptoms and disease, it is critical for clinicians to understand the rationale for specific therapies and their medical and practical implications for patients. In view of the opioid crisis, overall patient dissatisfaction, and lack of adherence to current chronic pain and headache therapies, this review provides up-to-date knowledge on cannabis as a potential treatment option for headache pain.

RECENT FINDINGS

Research into the use of cannabinoids for disease treatment have led to FDA-approved drugs for seizures, nausea, and vomiting caused by cancer chemotherapy; and for decreased appetite and weight loss in people with HIV/AIDS. For a wide variety of conditions and symptoms (including chronic pain), cannabis has gained increasing acceptance in society. The effects of cannabidiol (CBD) and tetrahydrocannabinol (THC) in pain pathways have been significantly elucidated. An increasing number of retrospective studies have shown a decrease in pain scores after administration of cannabinoids, as well as long-term benefits such as reduced opiate use. Yet, there is no FDA-approved cannabis product for headache or other chronic pain disorders. More is being done to determine who is likely to benefit from cannabis as well as to understand the long-term effects and limitations of the treatment. Cannabis can refer to a number of products derived from the plant Cannabis sativa L. Relatively well-tolerated, these products come in different configurations, types, and delivery forms. Specific formulations of the plant have been shown to be an effective treatment modality for chronic pain, including headache. It is important for clinicians to know which product is being discussed as well as the harms, benefits, contraindications, interactions, and unknowns in order to provide the best counsel for patients.

Prevalence of Medical Cannabis Use and Associated Health Conditions Documented in Electronic Health Records Among Primary Care Patients in Washington State

Importance

Many people use cannabis for medical reasons despite limited evidence of therapeutic benefit and potential risks. Little is known about medical practitioners' documentation of medical cannabis use or clinical characteristics of patients with documented medical cannabis use.

Objectives

To estimate the prevalence of past-year medical cannabis use documented in electronic health records (EHRs) and to describe patients with EHR-documented medical cannabis use, EHR-documented cannabis use without evidence of medical use (other cannabis use), and no EHR-documented cannabis use.

Design, Setting, and Participants

This cross-sectional study assessed adult primary care patients who completed a cannabis screen during a visit between November 1, 2017, and October 31, 2018, at a large health system that conducts routine cannabis screening in a US state with legal medical and recreational cannabis use.

Exposures

Three mutually exclusive categories of EHR-documented cannabis use (medical, other, and no use) based on practitioner documentation of medical cannabis use in the EHR and patient report of past-year cannabis use at screening.

Main Outcomes and Measures

Health conditions for which cannabis use has potential benefits or risks were defined based on National Academies of Sciences, Engineering, and Medicine's review. The adjusted prevalence of conditions diagnosed in the prior year were estimated across 3 categories of EHR-documented cannabis use with logistic regression.

Results

A total of 185 565 patients (mean [SD] age, 52.0 [18.1] years; 59% female, 73% White, 94% non-Hispanic, and 61% commercially insured) were screened for cannabis use in a primary care visit during the study period. Among these patients, 3551 (2%) had EHR-documented medical cannabis use, 36 599 (20%) had EHR-documented other cannabis use, and 145 415 (78%) had no documented cannabis use. Patients with medical cannabis use had a higher prevalence of health conditions for which cannabis has potential benefits (49.8%; 95% CI, 48.3%-51.3%) compared with patients with other cannabis use (39.9%; 95% CI, 39.4%-40.3%) or no cannabis use (40.0%; 95% CI, 39.8%-40.2%). In addition, patients with medical cannabis use had a higher prevalence of health conditions for which cannabis has potential risks (60.7%; 95% CI, 59.0%-62.3%) compared with patients with other cannabis use (50.5%; 95% CI, 50.0%-51.0%) or no cannabis use (42.7%; 95% CI, 42.4%-42.9%).

Conclusions and Relevance

In this cross-sectional study, primary care patients with documented medical cannabis use had a high prevalence of health conditions for which cannabis use has potential benefits, yet a higher prevalence of conditions with potential risks from cannabis use. These findings suggest that practitioners should be prepared to discuss potential risks and benefits of cannabis use with patients.

Endocannabinoid and dopaminergic system: the pas de deux underlying human motivation and behaviors

Endocannabinoid system (ECS) has been identified ever since cannabinoid, an active substance of Cannabis, was known to interact with endogenous cannabinoid (endocannabinoid/eCB) receptors. It later turned out that eCB was more intricate than previously thought. It has a pervasive role and exerts a multitude of cellular signaling mechanisms, regulating various physiological neurotransmission pathways in the human brain, including the dopaminergic (DA) system. eCB roles toward DA system were robust, clearly delineated, and reproducible with respect to physiological as well as pathological neurochemical and neurobehavioral manifestations of DA system, particularly those involving the nigrostriatal and mesocorticolimbic pathways. The eCB–DA system regulates the basics in the Maslow’s pyramid of hierarchy of needs required for individual survival such as food and sexual activity for reproductive purpose to those of higher needs in the pyramid, including self-actualization behaviors leading to achievement and reward (e.g., academic- and/or work-related performance and achievements). It is, thus, interesting to specifically discuss the eCB–DA system, not only on the molecular level, but also its tremendous potential to be developed as a future therapeutic strategy for various neuropsychiatric problems, including obesity, drug addiction and withdrawal, pathological hypersexuality, or low motivation behaviors.

Opioid Mortality Following Implementation of Medical Cannabis Programs in the United States

INTRODUCTION

The United States is in the midst of an opioid overdose epidemic. Emerging evidence suggests that medical cannabis (MC) may reduce use of opioids for pain in some individuals, with potential impacts on opioid-related overdose. However, there may be other important differences between states that did, and did not, adopt MC.

METHODS

This study evaluated differences following legal MC sales on US opioid-related overdose deaths, corrected for population, from 1999 to 2017 using an interrupted time series. Comparisons by MC status were also made for Medicaid expansion and the Centers for Disease Control death certificate reporting quality (0: <good, 1: good, 2: excellent).

RESULTS

Overdose deaths were significantly higher in MC states from 2012-2017. Overdose death slopes over time increased in states with (pre=1.46±0.46, post=2.90±0.58, p<0.05) and without (pre =0.20±.10, post=1.04±0.22, p<0.005) MC. Post-legalization slopes were significantly higher in MC states (p<0.01). Two states without (11.1%) as compared to 11 states with (91.7%) MC expanded Medicaid by 2014 (χ²[1]=19.03, p<0.0005). MC states (1.50±0.23) had higher death certificate reporting quality relative to states without MC (0.78±0.22, p<0.05).

DISCUSSION

MC states had higher rates of opioid overdoses. Although there was no decrease in association with MC introduction, these results were confounded by states without MC having lower overdose reporting quality. Medicaid expansion was also more common in states with MC. Finally, the potency of fentanyl analogues may have obscured any protective effects of MC against illicit opioid harms.

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.

The effectiveness of inhaled Cannabis flower for the treatment of agitation/irritability, anxiety, and common stress

BACKGROUND

An observational research design was used to evaluate which types of commonly labeled Cannabis flower product characteristics are associated with changes in momentary feelings of distress-related symptoms.

METHODS

We used data from 2306 patient-directed cannabis administration sessions among 670 people who used the real-time Cannabis effects recording software, Releaf App, between June 6, 2016, and February 23, 2019, for tracking the effects of Cannabis flower consumption. Fixed effects multivariable panel regression techniques were used to establish overall relief by symptom type and to determine which labeled product characteristics (e.g., subspecies/subtype, inhalation method, and major cannabinoid contents) showed the strongest correlation with changes in momentary feelings of agitation/irritability, anxiety, and stress, along with experienced side effects.

RESULTS

In total, a decrease in symptom intensity levels was reported in 95.51% of Cannabis usage sessions, an increase in 2.32% of sessions, and no change in 2.16% of sessions. Fixed effects models showed, on average, respondents recorded a maximum symptom intensity reduction of 4.33 points for agitation/irritability (SE = 0.20, p < 0.01), 3.47 points for anxiety (SE = 0.13, p < 0.01), and 3.98 for stress (SE = 0.12, p < 0.01) on an 11-point visual analog scale. Fixed effects regressions showed that, controlling for time-invariant user characteristics, mid and high tetrahydrocannabinol (THC) levels were the primary independent predictor of increased symptom relief, and that when broken out by symptom type, this effect was only statistically significant for our largest sample of users, those reporting anxiety rather than agitation/irritability or stress. Cannabidiol (CBD) levels were generally not associated with changes in symptom intensity levels. In a minority of cannabis use sessions (< 13%), cannabis users reported anxiogenic-related negative side effects (e.g., feeling anxious, irritable, paranoid, rapid pulse, or restless), whereas in a majority of sessions (about 66%), users reported positive anxiolytic side effects (e.g., feeling chill, comfy, happy, optimistic, peaceful, or relaxed).

CONCLUSIONS

The findings suggest the majority of patients in our sample experienced relief from distress-related symptoms following consumption of Cannabis flower, and that among product characteristics, higher THC levels were the strongest predictors of relief.

Exploring the Use of State Medical Cannabis Legislation as a Proxy for Medical Cannabis Use Among Patients Receiving Chemotherapy

OPINION STATEMENT

The use of medical cannabis is expanding in the USA. Due to conflicting, low-quality evidence, many oncologists may not feel confident to recommend it to patients. Given the potential for legal and financial risks when conducting clinical trials with medical cannabis, the use of observational data should be explored. Observational data that directly capture medical cannabis use in relation to prescription medications and track the prevalence and patterns of cannabis use is sparse. To gain insights into the role medical cannabis plays in the pharmaceutical landscape, proxies such as cannabis legislation need to be explored. In the context of recommendation-nonadherent antiemetic prescribing among patients experiencing chemotherapy-induced nausea and vomiting, medical cannabis may be a suitable alternative to an antiemetic in states that allow medical cannabis. Findings suggest that legislation may impact the use of certain antiemetics in states with cannabis legislation in place. The presence or absence of legislation regarding medical cannabis use may serve as an early, observable surrogate marker of medical cannabis use in the community. In light of the paucity of clinical trials and observational datasets that capture cannabis use, there remains a tremendous need for the development of methodologies or standardized datasets that appropriately and reliably capture the use of medical cannabis to facilitate research into its clinical application and effect on prescription medication use. Standardizing the reporting and destigmatizing use could eliminate the dependence upon proxy measures as a substitute for more extensive data and go a long way in improving data capture, thus allowing us to generate knowledge and hypotheses from observational data until research conditions improve and allow for expanded clinical trials involving medical cannabis.

Medical cannabis treatment for chronic pain: Outcomes and prediction of response

BACKGROUND

Although studied in a few randomized controlled trials, the efficacy of medical cannabis (MC) for chronic pain remains controversial. Using an alternative approach, this multicentre, questionnaire-based prospective cohort was aimed to assess the long-term effects of MC on chronic pain of various aetiologies and to identify predictors for MC treatment success.

METHODS

Patients with chronic pain, licensed to use MC in Israel, reported weekly average pain intensity (primary outcome) and related symptoms before and at 1, 3, 6, 9 and 12 months following MC treatment initiation. A general linear model was used to assess outcomes and identify predictors for treatment success (≥30% reduction in pain intensity).

RESULTS

A total of 1,045 patients completed the baseline questionnaires and initiated MC treatment, and 551 completed the 12-month follow-up. At 1 year, average pain intensity declined from baseline by 20% [-1.97 points (95%CI = -2.13 to -1.81; p < 0.001)]. All other parameters improved by 10%-30% (p < 0.001). A significant decrease of 42% [reduction of 27 mg; (95%CI = -34.89 to 18.56, p < 0.001)] from baseline in morphine equivalent daily dosage of opioids was also observed. Reported adverse effects were common but mostly non-serious. Presence of normal to long sleep duration, lower body mass index and lower depression score predicted relatively higher treatment success, whereas presence of neuropathic pain predicted the opposite.

CONCLUSIONS

This prospective study provides further evidence for the effects of MC on chronic pain and related symptoms, demonstrating an overall mild-to-modest long-term improvement of the tested measures and identifying possible predictors for treatment success.

Qualifying Conditions Of Medical Cannabis License Holders In The United States

The evidence for cannabis's treatment efficacy across different conditions varies widely, and comprehensive data on the conditions for which people use cannabis are lacking. We analyzed state registry data to provide nationwide estimates characterizing the qualifying conditions for which patients are licensed to use cannabis medically. We also compared the prevalence of medical cannabis qualifying conditions to recent evidence from the National Academies of Sciences, Engineering, and Medicine report on cannabis's efficacy in treating each condition. Twenty states and the District of Columbia had available registry data on patient numbers, and fifteen states had data on patient-reported qualifying conditions. Chronic pain is currently and historically the most common qualifying condition reported by medical cannabis patients (64.9 percent in 2016). Of all patient-reported qualifying conditions, 85.5 percent had either substantial or conclusive evidence of therapeutic efficacy. As medical cannabis use continues to increase, creating a nationwide patient registry would facilitate better understanding of trends in use and of its potential effectiveness.

Alleviative effects of Cannabis flower on migraine and headache

OBJECTIVE

Few studies to date have measured the real-time effects of consumption of common and commercially available Cannabis products for the treatment of headache and migraine under naturalistic conditions. This study examines, for the first time, the effectiveness of using dried Cannabis flower, the most widely used type of Cannabis product in the United States, in actual time for treatment of headache- and migraine-related pain and the associations between different product characteristics and changes in symptom intensity following Cannabis use.

METHODS

Between 06/10/2016 and 02/12/2019, 699 people used the Releaf Application to record real-time details of their Cannabis use, including product characteristics and symptom intensity levels prior to and following self-administration; data included 1910 session-level attempts to treat headache- (1328 sessions) or migraine-related pain (582 sessions). Changes in headache- or migraine-related pain intensity were measured on a 0-10 scale prior to, and immediately, following Cannabis consumption.

RESULTS

Ninety-four percent of users experienced symptom relief within a two-hour observation window. The average symptom intensity reduction was 3.3 points on a 0-10 scale (standard deviation = 2.28, Cohen's d = 1.58), with males experiencing greater relief than females (P < 0.001) and a trend that younger users (< 35 years) experience greater relief than older users (P = 0.08). Mixed effects regression models showed that, among the known (i.e., labeled) product characteristics, tetrahydrocannabinol levels 10% and higher are the strongest independent predictors of symptom relief, and this effect is particularly prominent in headache rather than migraine sufferers (P < 0.05), females (P < 0.05) and younger users (P < 0.001). Females and younger users also appear to gain greater symptom relief from flower labeled as "C. indica" rather than "C. sativa" or other hybrid strains.

CONCLUSION

These results suggest that whole dried Cannabis flower may be an effective medication for treatment of migraine- and headache-related pain, but the effectiveness differs according to characteristics of the Cannabis plant, the combustion methods, and the age and gender of the patient.

"Something that actually works": Cannabis use among young people in the context of street entrenchment

Background

Cannabis is one of the most widely used substances among vulnerable young people (<26 years of age) experiencing street entrenchment. Although previous research has documented the role cannabis can play in harm reduction, substance use and mental health treatment and pain management, this research has predominantly been quantitative and focused on adult drug-using populations. Little qualitative work has examined how young people who use drugs understand, experience, and engage with cannabis in the context of street entrenchment and drug use trajectories that include the use of other substances such as alcohol, opioids and crystal methamphetamine (meth).

Methods

Semi-structured, in-depth qualitative interviews were conducted between 2017 and 2019 with 56 young people recruited from a cohort of street-involved youth in Vancouver, Canada. We also conducted 13 interviews with 12 youth-focused care providers across the same time period. Interview data were triangulated by drawing on the findings of a program of anthropological research conducted by the senior author since 2008. Interviews were transcribed verbatim and thematic analysis was conducted.

Results

The vast majority of study participants engaged in daily, intensive cannabis use at the same time as they cycled on and off other substances that were perceived as much more harmful (primarily alcohol, fentanyl, heroin and meth). While most participants derived significant pleasure from the use of cannabis, no participants in our study described using cannabis for purely recreational purposes. A number of participants explicitly framed cannabis as a form of mental health and substance use treatment that was more effective and “healthier” than the long-term use of psychopharmaceuticals and medication-assisted substance use treatment (e.g., opioid agonist therapies). Cannabis use was also understood to ameliorate some of the harms of, or even facilitate transitions out of, periods of street-based homelessness. While the majority of our participants highlighted the positive effects of regular cannabis consumption, some described how intensive cannabis use could generate significant harms.

Conclusion

In the context of the recent legalization of non-medical cannabis use in Canada and amid ongoing overdose and housing crises, it is imperative that future policy and programming interventions and provider education and training be responsive to the ways in which vulnerable youth in our setting are actively using cannabis to navigate their everyday lives and healthcare needs.

Migraine Frequency Decrease Following Prolonged Medical Cannabis Treatment: A Cross-Sectional Study

Background: Medical cannabis (MC) treatment for migraine is practically emerging, although sufficient clinical data are not available for this indication. This cross-sectional questionnaire-based study aimed to investigate the associations between phytocannabinoid treatment and migraine frequency. Methods: Participants were migraine patients licensed for MC treatment. Data included self-reported questionnaires and MC treatment features. Patients were retrospectively classified as responders vs. non-responders (≥50% vs. <50% decrease in monthly migraine attacks frequency following MC treatment initiation, respectively). Comparative statistics evaluated differences between these two subgroups. Results: A total of 145 patients (97 females, 67%) with a median MC treatment duration of three years were analyzed. Compared to non-responders, responders (n = 89, 61%) reported lower current migraine disability and lower negative impact, and lower rates of opioid and triptan consumption. Subgroup analysis demonstrated that responders consumed higher doses of the phytocannabinoid ms_373_15c and lower doses of the phytocannabinoid ms_331_18d (3.40 95% CI (1.10 to 12.00); p < 0.01 and 0.22 95% CI (0.05–0.72); p < 0.05, respectively). Conclusions: These findings indicate that MC results in long-term reduction of migraine frequency in >60% of treated patients and is associated with less disability and lower antimigraine medication intake. They also point to the MC composition, which may be potentially efficacious in migraine patients.

The Role of the Cannabinoid System in Pain Control: Basic and Clinical Implications

PURPOSE OF REVIEW

The purpose of this review is to provide a comprehensive update of the different known components of the endogenous cannabinoid system and the mechanisms of action, as it applies to analgesia.

RECENT FINDINGS

Following the discovery of the endogenous cannabinoid system in the early 1990s and the subsequent characterization of the cannabinoid receptor, there has been a renewed interest in cannabinoid research. Recent work has demonstrated its efficacy as a pharmacologic agent. There is limited evidence in the literature about the understanding of the endocannabinoid system and its role in the treatment and management of acute and chronic pain. Further work may elucidate additional roles for the endocannabinoid system within our nervous system and, moreover, additional subtypes of cannabinoid receptors have yet to be discovered. Cannabinoid compounds mediate their biological effects via binding and subsequent activation of cannabinoid receptors. These receptors are located throughout the body and make up the endocannabinoid system. These receptors are best understood and have been cloned, type 1 (CB₁) and type 2 (CB₂) [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)]. The CB₂ receptor is located primarily in the immune system. CB₁ receptors are primarily located in the nervous system with the highest concentrations in the brain and lower concentrations in the spine and peripheral nervous tissues. Cannabinoids may be promising treatments for neuropathic pain with limited evidence, whereas, the evidence for other uses is insufficient.

The Therapeutic Effectiveness of Full Spectrum Hemp Oil Using a Chronic Neuropathic Pain Model

BACKGROUND

Few models exist that can control for placebo and expectancy effects commonly observed in clinical trials measuring 'Cannabis' pharmacodynamics. We used the Foramen Rotundum Inflammatory Constriction Trigeminal Infraorbital Nerve injury (FRICT-ION) model to measure the effect of "full-spectrum" whole plant extracted hemp oil on chronic neuropathic pain sensitivity in mice.

METHODS

Male BALBc mice were submitted to the FRICT-ION chronic neuropathic pain model with oral insertion through an incision in the buccal/cheek crease of 3 mm of chromic gut suture (4-0). The suture, wedged along the V2 trigeminal nerve branch, creates a continuous irritation that develops into secondary mechanical hypersensitivity on the snout. Von Frey filament stimuli on the mouse whisker pad was used to assess the mechanical pain threshold from 0-6 h following dosing among animals (n = 6) exposed to 5 μL of whole plant extracted hemp oil combined with a peanut butter vehicle (0.138 mg/kg), the vehicle alone (n = 3) 7 weeks post-surgery, or a naïve control condition (n = 3).

RESULTS

Mechanical allodynia was alleviated within 1 h (d = 2.50, p < 0.001) with a peak reversal effect at 4 h (d = 7.21, p < 0.001) and remained significant throughout the 6 h observation window. There was no threshold change on contralateral whisker pad after hemp oil administration, demonstrating the localization of anesthetic response to affected areas.

CONCLUSION

Future research should focus on how whole plant extracted hemp oil affects multi-sensory and cognitive-attentional systems that process pain.

Education and Training in Substance Use Disorders and Addictions: The University of New Mexico Integrated Training Model

This paper describes SUD/addictions training at the University of New Mexico. Coordinated and integrated academic, research, and clinical training resources are described, with an emphasis on the integration of resources across multiple training domains. Academic training resources in the Psychology Department include core clinical courses, basic science courses, and opportunities for students to develop expertise in health or quantitative psychology. Other academic resources come from affiliated departments and colleges such as Sociology, the College of Population Health, the College of Education, and Health Sciences. Research training resources are available within the Psychology Department, affiliated Departments and Colleges, and specialized research centers including the Center on Alcoholism, Substance Abuse, and Addictions, and the Mind Research Network. A network of community partners provides additional research sites. Clinical training resources are provided through a specialized alcohol treatment clinic and a diversity clinic within the Department, opportunities for students to serve as research clinicians, and community practicum sites supervised by on-site doctoral level psychologists or Departmental faculty. The UNM training program provides one model for graduate training in SUD/addictions. Keys to the program are the presence of multiple SUD/addictions clinical faculty member with active research programs, willingness to mentor students in research and clinical work, and basic science faculty whose research is relevant to addictive behaviors. Other critical elements include systematic development of clinical training opportunities, effective collaborations with community agencies for research and clinical training, meaningful research partnerships with other academic departments and specialized research centers, and external funding for training activities.

State marijuana laws and opioid overdose mortality

BACKGROUND

The opioid epidemic in the United States is a national public health crisis. In recent years, marijuana legalization has been increasingly adopted by state governments as a policy intervention to control the opioid epidemic under the premise that marijuana and opioids are substitutive substances. The purpose of this systematic review is to synthesize the empirical evidence regarding the impact of state marijuana laws on opioid overdose mortality and other opioid-related health outcomes.

METHOD

A comprehensive search of the research literature in 18 bibliographic databases returned 6640 records, with 5601 abstracts reviewed, 29 full text articles screened for eligibility, and 16 eligible studies included in the systematic review. Comprehensive Meta-Analysis software was used to generate summary estimates, forest plots, funnel plots, and heterogeneity statistics.

RESULTS

Of the 16 eligible studies, 4 assessed the association of state marijuana law status with opioid overdose mortality, 7 with prescription opioids dispensed, and the remaining with nonmedical use and opioid-related hospitalizations. Random effects modeling based on pooled data revealed that legalizing marijuana for medical use was associated with a statistically non-significant 8% reduction in opioid overdose mortality (95% confidence interval: - 0.21 to 0.04; p = 0.201) and a 7% reduction in prescription opioids dispensed (95% confidence interval: - 0.13 to - 0.01; p = 0.017). Legalizing marijuana for recreational use was associated with an additional 7% reduction in opioid overdose mortality in Colorado and 6% reduction in opioid prescriptions among fee-for-service Medicaid and managed care enrollees.

CONCLUSIONS

Legalizing marijuana might contribute to a modest reduction in opioid prescriptions. Evidence about the effect of marijuana legalization on opioid overdose mortality is inconsistent and inconclusive. If any, the effectiveness of state marijuana laws in reducing opioid overdose mortality appears to be rather small and limited to states with operational marijuana dispensaries. It remains unclear whether the presumed benefit of legalizing marijuana in reducing opioid-related harms outweighs the policy's externalities, such as its impact on mental health and traffic safety.

Cannabis Legalization Does Not Influence Patient Compliance with Opioid Therapy

BACKGROUND

Prescription opioid use and opioid related deaths continue to increase nationwide. Several states have adopted legislation allowing for recreational use of cannabis. Little is known about how recreational cannabis laws impact compliance in chronic pain patients who have been prescribed opioid therapy. The goals of this study were to (1) retrospectively assess the effect of cannabis use on compliance with opioid therapy in a high-risk patient population and (2) determine the impact of legalization of recreational cannabis on patients prescribed therapeutic opioids.

METHODS

We conducted a retrospective cohort study on results from a "high-risk" urine drug testing panel. Results from 1 year before and 1 year after initiation of recreational cannabis legislation were analyzed. This testing panel included qualitative assays for cannabinoids and 9 other common drugs of abuse in addition to a quantitative LC-MS/MS assay for 23 different opioids and metabolites. Opioid compliance was assigned by reviewing pathologists' interpretations.

RESULTS

In the pre-legalization period, 1776 panels were performed, and in the post-legalization, 1648 panels were performed. An increase (6%) in the rate of positive cannabinoids screening results was observed after legalization of recreational cannabis; however, the overall compliance rate was consistent.

CONCLUSIONS

The results of this study suggest that legalization of recreational cannabis does not affect compliance rate in patients treated with opioid therapy for chronic pain.

Perspectives on cannabis as a substitute for opioid analgesics

With the opioid epidemic reaching new heights in the USA, it has become critical to find suitable alternatives to opioids. Cannabis, an antinociceptive, is a strong contender to help patients reduce their opioid usage. A growing literature has been examining the complex effects cannabis has on pain relief and on opioid usage; whether it is a substitute for opioids or increases their use. This review explores the studies that compare cannabis-opioid interactions and presents some challenges of cannabis research and usage. The practical clinical pharmacology of cannabis as an analgesic, including the route of administration, safety and pharmacokinetics, are discussed to address the concerns, as well as possible solutions, of cannabis as a pain reliever.

Emerging Evidence for Cannabis' Role in Opioid Use Disorder

Introduction: The opioid epidemic has become an immense problem in North America, and despite decades of research on the most effective means to treat opioid use disorder (OUD), overdose deaths are at an all-time high, and relapse remains pervasive. Discussion: Although there are a number of FDA-approved opioid replacement therapies and maintenance medications to help ease the severity of opioid withdrawal symptoms and aid in relapse prevention, these medications are not risk free nor are they successful for all patients. Furthermore, there are legal and logistical bottlenecks to obtaining traditional opioid replacement therapies such as methadone or buprenorphine, and the demand for these services far outweighs the supply and access. To fill the gap between efficacious OUD treatments and the widespread prevalence of misuse, relapse, and overdose, the development of novel, alternative, or adjunct OUD treatment therapies is highly warranted. In this article, we review emerging evidence that suggests that cannabis may play a role in ameliorating the impact of OUD. Herein, we highlight knowledge gaps and discuss cannabis' potential to prevent opioid misuse (as an analgesic alternative), alleviate opioid withdrawal symptoms, and decrease the likelihood of relapse. Conclusion: The compelling nature of these data and the relative safety profile of cannabis warrant further exploration of cannabis as an adjunct or alternative treatment for OUD.

Patient-Reported Symptom Relief Following Medical Cannabis Consumption

Background: The Releaf App^TM mobile software application (app) data was used to measure self-reported effectiveness and side effects of medical cannabis used under naturalistic conditions.

Methods: Between 5/03/2016 and 12/16/2017, 2,830 Releaf App^TM users completed 13,638 individual sessions self-administering medical cannabis and indicated their primary health symptom severity rating on an 11-point (0–10) visual analog scale in real-time prior to and following cannabis consumption, along with experienced side effects.

Results: Releaf App^TM responders used cannabis to treat myriad health symptoms, the most frequent relating to pain, anxiety, and depressive conditions. Significant symptom severity reductions were reported for all the symptom categories, with mean reductions between 2.8 and 4.6 points (ds ranged from 1.29–2.39, ps < 0.001). On average, higher pre-dosing symptom levels were associated with greater reported symptom relief, and users treating anxiety or depression-related symptoms reported significantly more relief (ps < 0.001) than users with pain symptoms. Of the 42 possible side effects, users were more likely to indicate and showed a stronger correlation between symptom relief and experiences of positive (94% of sessions) or a context-specific side effects (76%), whereas negative side effects (60%) were associated with lessened, yet still significant symptom relief and were more common among patients treating a depressive symptom relative to patients treating anxiety and pain-related conditions.

Conclusion: Patient-managed cannabis use is associated with clinically significant improvements in self-reported symptom relief for treating a wide range of health conditions, along with frequent positive and negative side effects.

Effectiveness of Raw, Natural Medical Cannabis Flower for Treating Insomnia under Naturalistic Conditions

Background: We use a mobile software application (app) to measure for the first time, which fundamental characteristics of raw, natural medical Cannabis flower are associated with changes in perceived insomnia under naturalistic conditions. Methods: Four hundred and nine people with a specified condition of insomnia completed 1056 medical cannabis administration sessions using the Releaf App^TM educational software during which they recorded real-time ratings of self-perceived insomnia severity levels prior to and following consumption, experienced side effects, and product characteristics, including combustion method, cannabis subtypes, and/or major cannabinoid contents of cannabis consumed. Within-user effects of different flower characteristics were modeled using a fixed effects panel regression approach with standard errors clustered at the user level. Results: Releaf App^TM users showed an average symptom severity reduction of -4.5 points on a 0⁻10 point visual analogue scale (SD = 2.7, d = 2.10, p < 0.001). Use of pipes and vaporizers was associated with greater symptom relief and more positive and context-specific side effects as compared to the use of joints, while vaporization was also associated with lower negative effects. Cannabidiol (CBD) was associated with greater statistically significant symptom relief than tetrahydrocannabinol (THC), but the cannabinoid levels generally were not associated with differential side effects. Flower from C. sativa plants was associated with more negative side effects than flower from C. indica or hybrid plant subtypes. Conclusions: Consumption of medical Cannabis flower is associated with significant improvements in perceived insomnia with differential effectiveness and side effect profiles, depending on the product characteristics.

Cannabis for Chronic Pain: Challenges and Considerations

The National Academies of Sciences, Engineering, and Medicine has found substantial evidence that cannabis (plant) is effective for the treatment of chronic pain in adults, and moderate evidence that oromucosal cannabinoids (extracts, especially nabiximols) improve short-term sleep disturbances in chronic pain. The paradoxical superiority of the cannabis plant over cannabinoid molecules represents a challenge for the medical community and the established processes that define modern pharmacy. The expanding and variable legalization of cannabis in multiple states nationwide represents an additional challenge for patients and the medical community because recreational and medicinal cannabis are irresponsibly overlapped. Cannabis designed for recreational use (containing high levels of active ingredients) is increasingly available to patients with chronic pain who do not find relief with current pharmacologic entities, which exposes patients to potential harm. This article analyzes the available scientific evidence to address controversial questions that the current state of cannabis poses for health care professionals and chronic pain patients and sets the basis for a more open discussion about the role of cannabis in modern medicine for pain management. A critical discussion on these points, the legal status of cannabis, and considerations for health care providers is presented.