1
|
Cesur R, Sabia JJ, Bradford WD. The effect of combat deployments on veteran opioid abuse. HEALTH ECONOMICS 2024; 33:1284-1318. [PMID: 38424463 DOI: 10.1002/hec.4812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 01/23/2024] [Accepted: 01/28/2024] [Indexed: 03/02/2024]
Abstract
Grim national statistics about the U.S. opioid crisis are increasingly well known to the American public. Far less well known is that U.S. servicemembers are at ground zero of the epidemic, with veterans facing an overdose death rate of up to twice that of civilians. Exploiting a quasi-experiment in overseas deployment assignment, this study estimates the causal impact of combat exposure among the deployed in the Global War on Terrorism on opioid abuse. We find that exposure to war theater substantially increased the risk of prescription painkiller abuse and illicit heroin use among active duty servicemen. The magnitudes of our estimates imply lower-bound combat exposure-induced healthcare costs of $1.04 billion per year for prescription painkiller abuse and $470 million per year for heroin use.
Collapse
Affiliation(s)
- Resul Cesur
- Finance Department, University of Connecticut, NBER & IZA, Storrs, Connecticut, USA
| | - Joseph J Sabia
- Center for Health Economics & Policy Studies, San Diego State University and IZA, San Diego, California, USA
| | - W David Bradford
- Department of Public Administration & Policy, University of Georgia, Athens, Georgia, USA
| |
Collapse
|
2
|
Chrepa V, Villasenor S, Mauney A, Kotsakis G, Macpherson L. Cannabidiol as an Alternative Analgesic for Acute Dental Pain. J Dent Res 2024; 103:235-242. [PMID: 37910667 PMCID: PMC10900863 DOI: 10.1177/00220345231200814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023] Open
Abstract
Odontogenic pain can be debilitating, and nonopioid analgesic options are limited. This randomized placebo-controlled clinical trial aimed to assess the effectiveness and safety of cannabidiol (CBD) as an analgesic for patients with emergency acute dental pain. Sixty-one patients with moderate to severe toothache were randomized into 3 groups: CBD10 (CBD 10 mg/kg), CBD20 (CBD 20 mg/kg), and placebo. We administered a single dose of respective oral solution and monitored the subjects for 3 h. The primary outcome measure was the numerical pain differences using a visual analog scale (VAS) from baseline within and among the groups. Secondary outcome measures included ordinal pain intensity differences, the onset of significant pain relief, maximum pain relief, changes in bite force within and among the groups, psychoactive effects, mood changes, and other adverse events. Both CBD groups resulted in significant VAS pain reduction compared to their baseline and the placebo group, with a maximum median VAS pain reduction of 73% from baseline pain at the 180-min time point (P < 0.05). CBD20 experienced a faster onset of significant pain relief than CBD10 (15 versus 30 min after drug administration), and both groups reached maximum pain relief at 180-min. Number needed to treat was 3.1 for CBD10 and 2.4 for CBD20. Intragroup comparisons showed a significant increase in bite forces in both CBD groups (P < 0.05) but not in the placebo group (P > 0.05). CBD20 resulted in a significant difference in mean percent bite force change in the 90- and 180-min time points compared to the placebo group (P < 0.05). Compared to placebo, sedation, diarrhea, and abdominal pain were significantly associated with the CBD groups (P < 0.05). There were no other significant psychoactive or mood change effects. This randomized trial provides the first clinical evidence that oral CBD can be an effective and safe analgesic for dental pain.
Collapse
Affiliation(s)
- V. Chrepa
- UTHealth San Antonio, School of Dentistry, San Antonio, TX, USA
- Rutgers School of Dental Medicine, Newark, NJ
| | - S. Villasenor
- University of Texas at San Antonio, San Antonio, TX, USA
| | - A. Mauney
- University of Texas at San Antonio, San Antonio, TX, USA
| | - G. Kotsakis
- UTHealth San Antonio, School of Dentistry, San Antonio, TX, USA
- Rutgers School of Dental Medicine, Newark, NJ
| | - L. Macpherson
- University of Texas at San Antonio, San Antonio, TX, USA
| |
Collapse
|
3
|
Nguyen HV, McGinty EE, Mital S, Alexander GC. Recreational and Medical Cannabis Legalization and Opioid Prescriptions and Mortality. JAMA HEALTH FORUM 2024; 5:e234897. [PMID: 38241056 PMCID: PMC10799258 DOI: 10.1001/jamahealthforum.2023.4897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 11/18/2023] [Indexed: 01/22/2024] Open
Abstract
Importance While some have argued that cannabis legalization has helped to reduce opioid-related morbidity and mortality in the US, evidence has been mixed. Moreover, existing studies did not account for biases that could arise when policy effects vary over time or across states or when multiple policies are assessed at the same time, as in the case of recreational and medical cannabis legalization. Objective To quantify changes in opioid prescriptions and opioid overdose deaths associated with recreational and medical cannabis legalization in the US. Design, Setting, and Participants This quasiexperimental, generalized difference-in-differences analysis used annual state-level data between January 2006 and December 2020 to compare states that legalized recreational or medical cannabis vs those that did not. Intervention Recreational and medical cannabis law implementation (proxied by recreational and medical cannabis dispensary openings) between 2006 and 2020 across US states. Main Outcomes and Measures Opioid prescription rates per 100 persons and opioid overdose deaths per 100 000 population based on data from the US Centers for Disease Control and Prevention. Results Between 2006 and 2020, 13 states legalized recreational cannabis and 23 states legalized medical cannabis. There was no statistically significant association of recreational or medical cannabis laws with opioid prescriptions or overall opioid overdose mortality across the 15-year study period, although the results also suggested a potential reduction in synthetic opioid deaths associated with recreational cannabis laws (4.9 fewer deaths per 100 000 population; 95% CI, -9.49 to -0.30; P = .04). Sensitivity analyses excluding state economic indicators, accounting for additional opioid laws and using alternative ways to code treatment dates yielded substantively similar results, suggesting the absence of statistically significant associations between cannabis laws and the outcomes of interest during the full study period. Conclusions and Relevance The results of this study suggest that, after accounting for biases due to possible heterogeneous effects and simultaneous assessment of recreational and medical cannabis legalization, the implementation of recreational or medical cannabis laws was not associated with opioid prescriptions or opioid mortality, with the exception of a possible reduction in synthetic opioid deaths associated with recreational cannabis law implementation.
Collapse
Affiliation(s)
- Hai V. Nguyen
- School of Pharmacy, Memorial University of Newfoundland, St John’s, Newfoundland & Labrador, Canada
| | - Emma E. McGinty
- Division of Health Policy and Economics, Weill Cornell Medicine, New York, New York
| | - Shweta Mital
- College of Pharmacy, University of Manitoba, Winnipeg, Manitoba, Canada
| | - G. Caleb Alexander
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, Maryland
| |
Collapse
|
4
|
Sevigny EL, Greathouse J, Medhin DN. Health, safety, and socioeconomic impacts of cannabis liberalization laws: An evidence and gap map. CAMPBELL SYSTEMATIC REVIEWS 2023; 19:e1362. [PMID: 37915420 PMCID: PMC10616541 DOI: 10.1002/cl2.1362] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
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.
Collapse
Affiliation(s)
- Eric L. Sevigny
- Department of Criminal Justice and CriminologyGeorgia State UniversityAtlantaGeorgiaUSA
| | - Jared Greathouse
- Department of Criminal Justice and CriminologyGeorgia State UniversityAtlantaGeorgiaUSA
| | - Danye N. Medhin
- Department of Criminal Justice and CriminologyGeorgia State UniversityAtlantaGeorgiaUSA
| |
Collapse
|
5
|
Canals PC, Aguilar AG, Carter GT, Shields CM, Westerkamp A, D'Elia M, Aldrich J, Moore RN, Moore AT, Piper BJ. Patient Reported Outcomes Using Medical Cannabis for Managing Pain in Charcot-Marie-Tooth Disease. Am J Hosp Palliat Care 2023; 40:1163-1167. [PMID: 36793224 DOI: 10.1177/10499091231158388] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
Abstract
Objective: Chronic pain is a major problem for patients with Charcot-Marie-Tooth (CMT) disease. This exploratory study examined patient reported efficacy of medical cannabis for pain management in this population. Methods: Participants (N = 56; 71.4% female; Age = 48.9, SD = 14.6; 48.5% CMT1) were recruited though the Hereditary Neuropathy Foundation. The online survey contained 52 multiple choice questions about demographics, medical cannabis use, symptomology, efficacy, and adverse effects. Results: Nearly all (90.9%) of respondents reported experiencing pain, including all (100%) females and 72.7% of males (chi-square P < .05) with 91.7% of respondents indicating cannabis provided at least 50% pain relief. The most frequent response was an 80% reduction in pain. Moreover, 80.0% of respondents reported using less opiates, 69% noted using less sleep medication, and 50.0% reported using less anxiety/antidepressant medications. Negative side effects were noted by 23.5% of respondents. However, almost all (91.7%) of that subgroup did not have plans to stop consuming cannabis. One-third (33.9%) possessed a medical cannabis certificate. Patient perceptions of their physicians' attitudes regarding patient medical cannabis use greatly impacted whether respondents informed their providers of their usage. Conclusion: The vast majority of patients with CMT reported that cannabis was effective to manage pain symptoms. These data support the need for prospective, randomized, controlled trials using standardized dosing protocols to further delineate and optimize the potential use of cannabis to treat pain related to CMT.
Collapse
Affiliation(s)
- Priscilla C Canals
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | - Alexia G Aguilar
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | - Gregory T Carter
- Providence St Luke's Rehabilitation Medical Center, Hereditary Neuropathy Foundation Center of Excellence, Spokane, WA, USA
| | | | | | | | - Joy Aldrich
- Hereditary Neuropathy Foundation, New York, NY, USA
| | | | | | - Brian J Piper
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, PA, USA
- Center for Pharmacy Innovation and Outcomes, Precision Health Center, Forty Fort, PA, USA
| |
Collapse
|
6
|
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.
Collapse
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
| |
Collapse
|
7
|
Cook AC, Sirmans ET, Stype A. Medical cannabis laws lower individual market health insurance premiums. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 119:104143. [PMID: 37572391 DOI: 10.1016/j.drugpo.2023.104143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 07/10/2023] [Accepted: 07/15/2023] [Indexed: 08/14/2023]
Abstract
BACKGROUND To evaluate the impact of medical cannabis laws (MCLs) on health insurance premiums. We study whether cannabis legalization significantly impacts aggregate health insurer premiums in the individual market. Increases in utilization could have spillover effects to patients in the form of higher health insurance premiums. METHODS We use 2010-2021 state-level U.S. private health insurer financial data from the National Association of Insurance Commissioners. We examined changes to individual market health insurance premiums after the implementation of medical cannabis laws. We employed a robust difference-in-differences estimator that accounted for variation in policy timing to exploit temporal and geographic variation in state-level medical cannabis legalization. RESULTS Seven years after the implementation of Medical Cannabis laws, we observe lower health insurer premiums in the individual market. Starting seven years post-MCL implementation, we find a reduction of $-1662.7 (95% confidence interval [CI -2650.1, -605.7]) for states which implemented MCLs compared to the control group, a reduction of -$1541.8 (95% confidence interval [CI 2602.1, -481.4]) in year 8, and a reduction of $-1625.8, (95% confidence interval [CI -2694.2, -557.5]) in year 9. Due to the nature of insurance pooling and community rating, these savings are appreciated by cannabis users and non-users alike in states that have implemented MCLs. CONCLUSIONS The implementation of MCLs lowers individual-market health insurance premiums. Health insurance spending, including premiums, comprises between 16% and 34% of household budgets in the United States. As healthcare costs continue to rise, our findings suggest that households that obtain their health insurance on the individual (i.e., not employer sponsored) market in states with MCLs appreciate significantly lower premiums.
Collapse
Affiliation(s)
- Amanda C Cook
- 356C Schmidthorst College of Business, Department of Economics, Bowling Green State University, Bowling Green, OH 43403, United States.
| | - E Tice Sirmans
- Department of Finance, Insurance and Law, Illinois State University and Katie School of Insurance and Risk Management, United States
| | - Amanda Stype
- Department of Economics, Eastern Michigan University, United States
| |
Collapse
|
8
|
Kim K, Pacula RL, Dick AW, Stein BD, Druss BG, Agbese E, Cohrs AC, Leslie DL. Medical marijuana access and prolonged opioid use among adolescents and young adults. Am J Addict 2023; 32:479-487. [PMID: 37291067 PMCID: PMC10686234 DOI: 10.1111/ajad.13440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 03/19/2023] [Accepted: 05/23/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Laws liberalizing access to medical marijuana are associated with reduced opioid analgesic use among adults, but little is known about the impact of such policies on adolescents and young adults. METHODS This retrospective cohort study used 2005 to 2014 claims from MarketScan® Commercial database, which covers all 50 states and Washington D.C. The sample included 195,204 adolescent and young adult patients (aged 12-25) who underwent one of 13 surgical procedures. RESULTS Of the 195,204 patients, 4.8% had prolonged opioid use. Several factors were associated with a higher likelihood of prolonged opioid use, including being female (adjusted odds ratio [aOR], 1.27; 95% confidence interval [CI], 1.21-1.33), longer hospital stay (aOR, 1.04; 95% CI, 1.02-1.06), greater days of index opioid supply (8-14 days: aOR, 1.39, 95% CI, 1.33-1.45; greater than 14 days: aOR, 2.42, 95% CI, 2.26-2.59), rural residence (aOR, 1.07; 95% CI, 1.01-1.14), and cholecystectomy (aOR, 1.16; 95% CI, 1.08-1.25). There was not a significant association of medical marijuana dispensary laws on prolonged opioid use (aOR, 0.98; 95% CI, 0.81-1.18). CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE Medical marijuana has been suggested as a substitute for opioids, but our results focusing on adolescents and young adults provide new evidence that this particularly vulnerable population does not exhibit reductions in prolonged use of opioids after surgery when they have legal access to medical marijuana. These findings are the first to demonstrate potentially important age differences in sustained use of opioids, and point to the need for prescriber oversight and management with this vulnerable population.
Collapse
Affiliation(s)
- Kyungha Kim
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Rosalie L. Pacula
- Sol Price School of Public Policy, Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, California, USA
| | | | | | - Benjamin G. Druss
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Edeanya Agbese
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Austin C. Cohrs
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Douglas L. Leslie
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania, USA
| |
Collapse
|
9
|
McGinty EE, Tormohlen KN, Seewald NJ, Bicket MC, McCourt AD, Rutkow L, White SA, Stuart EA. Effects of U.S. State Medical Cannabis Laws on Treatment of Chronic Noncancer Pain. Ann Intern Med 2023; 176:904-912. [PMID: 37399549 DOI: 10.7326/m23-0053] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND State medical cannabis laws may lead patients with chronic noncancer pain to substitute cannabis in place of prescription opioid or clinical guideline-concordant nonopioid prescription pain medications or procedures. OBJECTIVE To assess effects of state medical cannabis laws on receipt of prescription opioids, nonopioid prescription pain medications, and procedures for chronic noncancer pain. DESIGN Using data from 12 states that implemented medical cannabis laws and 17 comparison states, augmented synthetic control analyses estimated laws' effects on receipt of chronic noncancer pain treatment, relative to predicted treatment receipt in the absence of the law. SETTING United States, 2010 to 2022. PARTICIPANTS 583 820 commercially insured adults with chronic noncancer pain. MEASUREMENTS Proportion of patients receiving any opioid prescription, nonopioid prescription pain medication, or procedure for chronic noncancer pain; volume of each treatment type; and mean days' supply and mean morphine milligram equivalents per day of prescribed opioids, per patient in a given month. RESULTS In a given month during the first 3 years of law implementation, medical cannabis laws led to an average difference of 0.05 percentage points (95% CI, -0.12 to 0.21 percentage points), 0.05 percentage points (CI, -0.13 to 0.23 percentage points), and -0.17 percentage points (CI, -0.42 to 0.08 percentage points) in the proportion of patients receiving any opioid prescription, any nonopioid prescription pain medication, or any chronic pain procedure, respectively, relative to what we predict would have happened in that month had the law not been implemented. LIMITATIONS This study used a strong nonexperimental design but relies on untestable assumptions involving parallel counterfactual trends. Statistical power is limited by the finite number of states. Results may not generalize to noncommercially insured populations. CONCLUSION This study did not identify important effects of medical cannabis laws on receipt of opioid or nonopioid pain treatment among patients with chronic noncancer pain. PRIMARY FUNDING SOURCE National Institute on Drug Abuse.
Collapse
Affiliation(s)
- Emma E McGinty
- Division of Health Policy and Economics, Weill Cornell Medicine, New York, New York (E.E.M.)
| | - Kayla N Tormohlen
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (K.N.T., N.J.S., A.D.M., L.R., S.A.W.)
| | - Nicholas J Seewald
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (K.N.T., N.J.S., A.D.M., L.R., S.A.W.)
| | - Mark C Bicket
- Departments of Anesthesiology and Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan (M.C.B.)
| | - Alexander D McCourt
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (K.N.T., N.J.S., A.D.M., L.R., S.A.W.)
| | - Lainie Rutkow
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (K.N.T., N.J.S., A.D.M., L.R., S.A.W.)
| | - Sarah A White
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (K.N.T., N.J.S., A.D.M., L.R., S.A.W.)
| | - Elizabeth A Stuart
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (E.A.S.)
| |
Collapse
|
10
|
Raman S, Maclean JC, Bradford WD, Drake C. Recreational cannabis and opioid distribution. HEALTH ECONOMICS 2023; 32:747-754. [PMID: 36653623 DOI: 10.1002/hec.4652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 12/07/2022] [Accepted: 01/05/2023] [Indexed: 06/17/2023]
Abstract
Twenty-one U.S. states have passed recreational cannabis laws as of November 2022. Cannabis may be a substitute for prescription opioids in the treatment of chronic pain. Previous studies have assessed recreational cannabis laws' effects on opioid prescriptions financed by specific private or public payers or dispensed to a unique endpoint. Our study adds to the literature in three important ways: by (1) examining these laws' impacts on prescription opioid dispensing across all payers and endpoints, (2) adjusting for important opioid-related policies such as opioid prescribing limits, and (3) modeling opioids separately by type. We implement two-way fixed-effects regressions and leverage variation from eleven U.S. states that adopted a recreational cannabis law (RCL) between 2010 and 2019. We find that RCLs lead to a reduction in codeine dispensed at retail pharmacies. Among prescription opioids, codeine is particularly likely to be used non-medically. Thus, the finding that RCLs appear to reduce codeine dispensing is potentially promising from a public health perspective.
Collapse
Affiliation(s)
- Shyam Raman
- Jeb E. Brooks School of Public Policy, Cornell University, Ithaca, New York, USA
| | | | - W David Bradford
- School of Public and International Affairs, University of Georgia, Athens, Georgia, USA
| | - Coleman Drake
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
11
|
Ali MM, McClellan C, Mutter R, Rees DI. Recreational marijuana laws and the misuse of prescription opioids: Evidence from National Survey on Drug Use and Health microdata. HEALTH ECONOMICS 2023; 32:277-301. [PMID: 36335085 DOI: 10.1002/hec.4620] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 08/30/2022] [Accepted: 09/28/2022] [Indexed: 06/16/2023]
Abstract
Several studies have concluded that legalizing medical marijuana can reduce deaths from opioid overdoses. Drawing on micro data from the National Survey on Drug Use and Health, a survey uniquely suited to assessing patterns of substance use, we examine the relationship between recreational marijuana laws (RMLs) and the misuse of prescription opioids. Using a standard difference-in-differences (DD) regression model, we find that RML adoption reduces the likelihood of frequently misusing prescription opioids such as OxyContin, Percocet, and Vicodin. However, using a two-stage procedure designed to account for staggered treatment and dynamic effects, the DD estimate of relationship between RML adoption and the likelihood of frequently misusing prescription opioids becomes positive. Although event study estimates suggest that RML adoption leads to a decrease in the frequency of prescription opioid abuse, this effect appears to dissipate after only 2 or 3 years.
Collapse
Affiliation(s)
- Mir M Ali
- Office of the Assistant Secretary for Planning and Evaluation, Washington, District of Columbia, USA
| | - Chandler McClellan
- Agency for Healthcare Research and Quality, North Bethesda, Maryland, USA
| | - Ryan Mutter
- Congressional Budget Office, Washington, District of Columbia, USA
| | | |
Collapse
|
12
|
Bao Y, Zhang H, Bruera E, Portenoy R, Rosa WE, Reid MC, Wen H. Medical Marijuana Legalization and Opioid- and Pain-Related Outcomes Among Patients Newly Diagnosed With Cancer Receiving Anticancer Treatment. JAMA Oncol 2023; 9:206-214. [PMID: 36454553 PMCID: PMC9716439 DOI: 10.1001/jamaoncol.2022.5623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 09/12/2022] [Indexed: 12/03/2022]
Abstract
Importance The past decade saw rapid declines in opioids dispensed to patients with active cancer, with a concurrent increase in marijuana use among cancer survivors possibly associated with state medical marijuana legalization. Objective To assess the associations between medical marijuana legalization and opioid-related and pain-related outcomes for adult patients receiving cancer treatment. Design, Setting, and Participants This cross-sectional study used 2012 to 2017 national commercial claims data and a difference-in-differences design to estimate the associations of interest for patients residing in 34 states without medical marijuana legalization by January 1, 2012. Secondary analysis differentiated between medical marijuana legalization with and without legal allowances for retail dispensaries. Data analysis was conducted between December 2021 and August 2022. Study samples included privately insured patients aged 18 to 64 years who received anticancer treatment during the 6 months after a new breast (in women), colorectal, or lung cancer diagnosis. Exposures State medical marijuana legalization that took effect between 2012 and 2017. Main Outcomes and Measures Having 1 or more days of opioids, 1 or more days of long-acting opioids, total morphine milligram equivalents of any opioid dispensed to patients with 1 or more opioid days, and 1 or more pain-related emergency department visits or hospitalizations (hereafter, hospital events) during the 6 months after a new cancer diagnosis. Interaction terms were included between each policy indicator and an indicator of recent opioids, defined as having 1 or more opioid prescriptions during the 12 months before the new cancer diagnosis. Logistic models were estimated for dichotomous outcomes, and generalized linear models were estimated for morphine milligram equivalents. Results The analysis included 38 189 patients newly diagnosed with breast cancer (38 189 women [100%]), 12 816 with colorectal cancer (7100 men [55.4%]), and 7190 with lung cancer (3674 women [51.1%]). Medical marijuana legalization was associated with a reduction in the rate of 1 or more opioid days from 90.1% to 84.4% (difference, 5.6 [95% CI, 2.2-9.0] percentage points; P = .001) among patients with breast cancer with recent opioids, from 89.4% to 84.4% (difference, 4.9 [95% CI, 0.5-9.4] percentage points; P = .03) among patients with colorectal cancer with recent opioids, and from 33.8% to 27.2% (difference, 6.5 [95% CI, 1.2-11.9] percentage points; P = .02) among patients with lung cancer without recent opioids. Medical marijuana legalization was associated with a reduction in the rate of 1 or more pain-related hospital events from 19.3% to 13.0% (difference, 6.3 [95% CI, 0.7-12.0] percentage points; P = .03) among patients with lung cancer with recent opioids. Conclusions and Relevance Findings of this cross-sectional study suggest that medical marijuana legalization implemented from 2012 to 2017 was associated with a lower rate of opioid dispensing and pain-related hospital events among some adults receiving treatment for newly diagnosed cancer. The nature of these associations and their implications for patient safety and quality of life need to be further investigated.
Collapse
Affiliation(s)
- Yuhua Bao
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York
- Department of Psychiatry, Weill Cornell Medicine, New York, New York
| | - Hao Zhang
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Russell Portenoy
- MJHS Institute for Innovation in Palliative Care, New York, New York
- Saul R. Korey Department of Neurology, Albert Einstein College of Medicine, New York, New York
- Department of Family and Social Medicine, Albert Einstein College of Medicine, New York, New York
| | - William E. Rosa
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Hefei Wen
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| |
Collapse
|
13
|
Holman A, Kruger DJ, Lucas P, Ong K, Bergmans RS, Boehnke KF. Healthcare provider and medical cannabis patient communication regarding referral and medication substitution: the Canadian context. J Cannabis Res 2022; 4:32. [PMID: 35698183 PMCID: PMC9195481 DOI: 10.1186/s42238-022-00141-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 05/31/2022] [Indexed: 11/18/2022] Open
Abstract
Background Patients use medical cannabis for a wide array of illnesses and symptoms, and many substitute cannabis for pharmaceuticals. This substitution often occurs without physician oversight, raising patient safety concerns. We aimed to characterize substitution and doctor-patient communication patterns in Canada, where there is a mature market and national regulatory system for medical cannabis. Methods We conducted an anonymous, cross-sectional online survey in May 2021 for seven days with adult Canadian federally-authorized medical cannabis patients (N = 2697) registered with two global cannabis companies to evaluate patient perceptions of Primary Care Provider (PCP) knowledge of medical cannabis and communication regarding medical cannabis with PCPs, including PCP authorization of licensure and substitution of cannabis for other medications. Results Most participants (62.7%, n = 1390) obtained medical cannabis authorization from their PCP. Of those who spoke with their PCP about medical cannabis (82.2%, n = 2217), 38.6% (n = 857) reported that their PCP had “very good” or “excellent” knowledge of medical cannabis and, on average, were moderately confident in their PCP’s ability to integrate medical cannabis into treatment. Participants generally reported higher ratings for secondary care providers, with 82.8% (n = 808) of participants rating their secondary care provider’s knowledge about medical cannabis as “very good” or “excellent.” Overall, 47.1% (n = 1269) of participants reported substituting cannabis for pharmaceuticals or other substances (e.g., alcohol, tobacco/nicotine). Of these, 31.3% (n = 397) reported a delay in informing their PCP of up to 6 months or more, and 34.8% (n = 441) reported that their PCP was still not aware of their substitution. Older, female participants had higher odds of disclosing cannabis substitution to their PCPs. Conclusion Most of the surveyed Canadian medical cannabis patients considered their PCPs knowledgeable about cannabis and were confident in their PCPs’ ability to integrate cannabis into treatment plans. However, many surveyed patients substituted cannabis for other medications without consulting their PCPs. These results suggest a lack of integration between mainstream healthcare and medical cannabis that may be improved through physician education and clinical experience. Supplementary Information The online version contains supplementary material available at 10.1186/s42238-022-00141-0.
Collapse
|
14
|
Bednarek Z, Doremus JM, Stith SS. U.S. cannabis laws projected to cost generic and brand pharmaceutical firms billions. PLoS One 2022; 17:e0272492. [PMID: 36044436 PMCID: PMC9432746 DOI: 10.1371/journal.pone.0272492] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 07/20/2022] [Indexed: 11/19/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Ziemowit Bednarek
- Orfalea College of Business, California Polytechnic State University, San Luis Obispo, California, United States of America
- * E-mail:
| | - Jacqueline M. Doremus
- Orfalea College of Business, California Polytechnic State University, San Luis Obispo, California, United States of America
| | - Sarah S. Stith
- Department of Economics, University of New Mexico, Albuquerque, New Mexico, United States of America
| |
Collapse
|
15
|
Raman S, Bradford AC. Recreational cannabis legalizations associated with reductions in prescription drug utilization among Medicaid enrollees. HEALTH ECONOMICS 2022; 31:1513-1521. [PMID: 35429072 DOI: 10.1002/hec.4519] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 03/30/2022] [Accepted: 04/01/2022] [Indexed: 06/14/2023]
Abstract
The potential substitution of cannabis for prescription medication has attracted a substantial amount of attention within the context of medical cannabis laws (MCLs). However, much less is known about the association between recreational cannabis laws (RCLs) and prescription drug use. With recent evidence supporting substitution of cannabis for prescription drugs following MCLs, it is reasonable to ask what effect RCLs may have on those outcomes. We use quarterly data for all Medicaid prescriptions from 2011 to 2019 to investigate the effect of state-level RCLs on prescription drug utilization. We estimate this effect with a series of two-way fixed effects event study models. We find significant reductions in the volume of prescriptions within the drug classes that align with the medical indications for pain, depression, anxiety, sleep, psychosis, and seizures. Our results suggest substitution away from prescription drugs and potential cost savings for state Medicaid programs.
Collapse
Affiliation(s)
- Shyam Raman
- Jeb E. Brooks School of Public Policy, Cornell University, Ithaca, New York, USA
| | - Ashley C Bradford
- O'Neill School of Public and Environmental Affairs, Indiana University, Bloomington, Indiana, USA
| |
Collapse
|
16
|
Chay J, Kim S. Heterogeneous health effects of medical marijuana legalization: Evidence from young adults in the United States. HEALTH ECONOMICS 2022; 31:269-283. [PMID: 34755415 DOI: 10.1002/hec.4452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 08/31/2021] [Accepted: 10/18/2021] [Indexed: 06/13/2023]
Abstract
Legalizing marijuana for medical purposes is a longstanding debate. However, evidence of marijuana's health effects is limited, especially for young adults. We estimate the health impacts of medical marijuana laws (MML) in the U.S. among young adults aged 18-29 years using the difference-in-differences method and data from the Behavioral Risk Factors Surveillance System. We find that having MMLs with strict regulations generate health gains, but not in states with lax regulations. Our heterogeneity analysis results indicate that individuals with lower education attainments, with lower household income and without access to health insurance coverage gain more health benefits from MML with strict regulations than from MML with lax regulations. The findings suggest greater net health gains under strict controls concerning marijuana supply and access.
Collapse
Affiliation(s)
- Junxing Chay
- School of Economics, Singapore Management University, Singapore
| | - Seonghoon Kim
- School of Economics, Singapore Management University, Singapore
| |
Collapse
|
17
|
French MT, Zukerberg J, Lewandowski TE, Piccolo KB, Mortensen K. Societal Costs and Outcomes of Medical and Recreational Marijuana Policies in the United States: A Systematic Review. Med Care Res Rev 2022; 79:743-771. [PMID: 35068253 DOI: 10.1177/10775587211067315] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Significant support exists in the United States for legalization of marijuana/cannabis. As of 2021, 36 states and four territories approved the legalization of medical cannabis via medical marijuana laws (MMLs), and 15 states and District of Columbia (DC) have adopted recreational marijuana laws (RMLs). We performed structured and systematic searches of articles published from 2010 through September 2021. We assess the literature pertaining to adolescent marijuana use; opioid use and opioid-related outcomes; alcohol use; tobacco use; illicit and other drug use; marijuana growing and cultivation; employment, earnings, and other workplace outcomes; academic achievement and performance; criminal activity; perceived harmfulness; traffic and road safety; and suicide and sexual activity. Overall, 113 articles satisfied our inclusion criteria. Except for opioids, studies on use of other substances (illicit drugs, tobacco, and alcohol) were inconclusive. MMLs and RMLs do not generate negative outcomes in the labor market, lead to greater criminal activity, or reduce traffic and road safety.
Collapse
|
18
|
Kim JH, Martins SS, Shmulewitz D, Hasin D. Association between fatal opioid overdose and state medical cannabis laws in US national survey data, 2000-2011. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 99:103449. [PMID: 34587580 PMCID: PMC8755580 DOI: 10.1016/j.drugpo.2021.103449] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/25/2021] [Accepted: 08/30/2021] [Indexed: 02/09/2023]
Abstract
AIMS Most information on the relationship between medical cannabis laws (MCL) and the risk for opioid overdose fatality has been based on studies with ecological designs. To contribute additional information, we used a novel case-control design and individual-level data from national surveys to assess whether state medical cannabis laws were associated with reduced risk of fatal opioid overdose between 2000-2011. METHODS Data from participants surveyed in the National Health Interview Survey (NHIS) between 1986-2011 were included. For those sampled between 1986-2009, detailed mortality follow-up data were available from the National Death Index up to 12/31/2011. Opioid overdose decedents (n = 791) were classified as cases. Between 2000-2011, all cases arising in a given year were matched to adult controls who were surveyed the same year and eligible for mortality follow-up (n = 723,920). The distribution of exposure to state MCL was contrasted between cases and controls, providing an approximation of the rate ratio of fatal opioid overdose associated with MCLs. Due to a NHIS sample redesign, we stratified analysis using timeframes before and after 2005. RESULTS Overall, compared to controls, cases were more likely to be male, middle-aged, non-Hispanic White, separated/divorced; less educated, and have a family income below the poverty threshold. No overall association between state MCLs and the rate of opioid overdose was observed between 2000-2005 (aOR = 1.22, 95% CI: 0.83-1.79) or between 2006-2011 (aOR = 0.87, 95% CI: 0.60-1.25). No significant difference between sampling timeframes was observed (ratio of aOR's = 0.71, 95% CI: 0.49-1.01). CONCLUSIONS We found no overall protective relationship between state MCLs and opioid overdose. Future research with more recent mortality data and more refined cannabis policy classifications would be useful. The importance of the study is two-fold. First, the findings provide an additional source of information countering claims of a protective effect of MCLs on opioid overdoses, suggesting that other solutions to the opioid overdose crisis are needed. Second, the study offers a potentially useful design to answer important population-level public health questions.
Collapse
Affiliation(s)
- June H. Kim
- New York State Psychiatric Institute, New York
| | - Silvia S. Martins
- Department of Epidemiology, Mailman School of Public Health, Columbia University Irving Medical Center, New York
| | - Dvora Shmulewitz
- Department of Psychiatry, Columbia University Irving Medical Center, New York, New York State Psychiatric Institute, New York
| | - Deborah Hasin
- Department of Psychiatry, Columbia University Irving Medical Center, New York, New York State Psychiatric Institute, New York, Department of Epidemiology, Mailman School of Public Health, Columbia University Irving Medical Center, New York
| |
Collapse
|
19
|
Abstract
Cannabis use in the United States is growing at an unprecedented pace. Most states in the United States have legalized medical cannabis use, and many have legalized nonmedical cannabis use. In this setting, health care professionals will increasingly see more patients who have questions about cannabis use, its utility for medical conditions, and the risks of its use. This narrative review provides an overview of the background, pharmacology, therapeutic use, and potential complications of cannabis.
Collapse
Affiliation(s)
- Deepika E Slawek
- Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA.
| | - Susanna A Curtis
- Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA. https://twitter.com/DrSusieC2
| | - Julia H Arnsten
- Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA. https://twitter.com/DrArnsten
| | - Chinazo O Cunningham
- Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA. https://twitter.com/DrChinazo
| |
Collapse
|
20
|
Bhagianadh D, Arora K. Legalization of Medical Cannabis and Site of Death: Evidence From National Vital Statistics Mortality Data. J Appl Gerontol 2021; 41:806-816. [PMID: 34930063 DOI: 10.1177/07334648211058720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We examined whether Medical Marijuana Legislation (MML) was associated with site of death. Using state-level data (1992-2018) from the National Vital Statistics System (NVSS), we employed difference-in-differences method to compare changes in death rate among older adults at four sites-nursing home (NH), hospital, home, hospice/other-over time in states with and without MML. Heterogeneity analyses were conducted by timing of MML adoption, and by decedent characteristics. Results show a negative association between MML implementation and NH deaths. Among early adopters (states with weakly regulated programs) and decedents with musculoskeletal disorders, there was a positive association between MML implementation and hospital deaths, whereas among late adopters (states with "medicalized" programs), there was a positive association between MML implementation and hospice deaths. Decline in NH deaths may reflect increased likelihood of transfers due to threat of Federal enforcement, penalties for poor outcomes, and liability concerns. Future studies should examine these associations further.
Collapse
Affiliation(s)
- Divya Bhagianadh
- Department of Health Management and Policy, University of Iowa, Iowa City, IA, USA
| | - Kanika Arora
- Department of Health Management and Policy, University of Iowa, Iowa City, IA, USA
| |
Collapse
|
21
|
Mauro PM, Philbin MM, Greene ER, Askari MS, Martins SS. Medical and Non-Medical Opioid Use at the Intersection of Gender and Sexual Identity: Associations with State Medical Cannabis Law Status in a U.S. National Sample of Adults. ARCHIVES OF SEXUAL BEHAVIOR 2021; 50:3551-3561. [PMID: 34751862 PMCID: PMC8729119 DOI: 10.1007/s10508-021-02128-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 08/05/2021] [Accepted: 08/05/2021] [Indexed: 06/13/2023]
Abstract
At the structural level, medical cannabis laws (MCLs) have been negatively associated with opioid prescribing practices, and sexual minority adults report disproportionately high non-medical prescription opioid use. We examined medical/non-medical prescription opioid use by intersecting sexual identity and gender and explored associations with MCLs using the 2015-2017 National Survey on Drug Use and Health, which captured sexual identity and MCL state residence for adults 18 + years (N = 126,463). Survey-weighted gender-stratified multinomial logistic models estimated adjusted relative risk ratios (aRRR) of medical vs. no prescription opioid use, and any non-medical vs. no prescription opioid use, by sexual identity and MCL, and tested moderation by MCL. Past-year medical prescription opioid use was higher among women than men across sexual identities (e.g., bisexual: 38.5% women vs. 30.2% men). Non-medical prescription opioid use was lower among women than men, except for bisexual adults (12.4% women vs. 7.6% men). MCL was associated with lower medical prescription opioid vs. no use among heterosexual women (aRRR = 0.86, 95% confidence interval [CI] = 0.81-0.91), bisexual women (aRRR = 0.74, 95% CI = 0.62-0.89), and heterosexual men (aRRR = 0.91, 95% CI = 0.85-0.97). Living in an MCL state was associated with lower non-medical vs. no use among heterosexual and bisexual women, but not among men or lesbian/gay women. MCL status did not moderate associations between sexual identity and prescription opioid outcomes. Future studies should assess whether implementing MCLs could particularly affect bisexual women who reported the highest prescription opioid use and may need targeted services.
Collapse
Affiliation(s)
- Pia M Mauro
- Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 W 168th Street, New York, NY, 10032, USA.
| | - Morgan M Philbin
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Emily R Greene
- Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 W 168th Street, New York, NY, 10032, USA
| | - Melanie S Askari
- Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 W 168th Street, New York, NY, 10032, USA
| | - Silvia S Martins
- Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 W 168th Street, New York, NY, 10032, USA
| |
Collapse
|
22
|
Tormohlen KN, Bicket MC, White S, Barry CL, Stuart EA, Rutkow L, McGinty EE. The State of the Evidence on the Association Between State Cannabis Laws and Opioid-Related Outcomes: a Review. CURRENT ADDICTION REPORTS 2021; 8:538-545. [DOI: 10.1007/s40429-021-00397-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
23
|
Lebesmuehlbacher T, Smith RA. The effect of medical cannabis laws on pharmaceutical marketing to physicians. HEALTH ECONOMICS 2021; 30:2409-2436. [PMID: 34258798 DOI: 10.1002/hec.4380] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 06/02/2021] [Accepted: 06/04/2021] [Indexed: 06/13/2023]
Abstract
Although cannabis is federally prohibited, a majority of U.S. states have implemented medical cannabis laws (MCLs). As more individuals consider the drug for medical treatment, they potentially substitute away from prescription drugs. Therefore, an MCL signals competitor entry. This paper exploits geographic and temporal variation in MCLs to examine the strategic response in direct-to-physician marketing by pharmaceutical firms as cannabis enters the market. Using office detailing records from 2014-2018 aggregated to the county level, we find weak evidence of a relatively small and delayed response in substitute prescription drug- and opioid-related detailing. While these effects on detailing dollars are more pronounced among smaller pharmaceutical firms, the magnitudes are economically small and likely muted at aggregate levels by the small percent of doctors that actively recommend cannabis for medical treatment.
Collapse
Affiliation(s)
| | - Rhet A Smith
- Department of Economics & Finance, University of Arkansas at Little Rock, Little Rock, Arkansas, USA
| |
Collapse
|
24
|
Lucas P, Walsh Z, Hendricks PS, Boyd S, Milloy MJ. Self-reported reductions in tobacco and nicotine use following medical cannabis initiation: Results from a cross-sectional survey of authorized medical cannabis patients in Canada. J Subst Abuse Treat 2021; 130:108481. [PMID: 34118713 DOI: 10.1016/j.jsat.2021.108481] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 02/18/2021] [Accepted: 05/11/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND Despite decades of campaigns aimed at reducing tobacco/nicotine (T/N) use and the development of many different T/N reduction and cessation strategies, the impacts on international public health remain significant. Some studies have found an association between medical and non-medical cannabis use and T/N use, although the evidence on whether cannabis/cannabinoids increase or decrease the odds of reducing or ceasing T/N use remain contradictory. This paper explores the self-reported use of cannabis and associated changes in T/N use among a Canadian medical cannabis patient population. METHODS This study examines the impact of medical cannabis on T/N use by comparing self-reported patterns of use before and after the initiation of medical cannabis. Participants completed an online cross-sectional survey examining demographics, patterns of medical cannabis use, and the impact of medical cannabis on the use of T/N and other substances. The survey also included novel measures examining whether patients intended to use medical cannabis to reduce T/N use or had experience with other pharmacological or psychobehavioral T/N cessation strategies. We conducted a series of descriptive analyses and univariate and multivariate logistic regressions to explore the potential association between primary variables of interest and T/N reduction and cessation. RESULTS In total, the study recruited 2102 individuals, of whom 650 were current or former T/N users. Following initiation of medical cannabis use 320 (49%) T/N users self-reported reductions in use, with 160 (24.6%) reporting no T/N use in the 30 days prior to the survey. Odds of T/N cessation were greater among those who were age 55 or older (Adjusted Odds Ratio [AOR] = 2.56, 95% Confidence Interval [CI] 1.53-4.26), or those who reported >25 T/N uses per day in the pre-period (AOR = 2.11, 95% CI 1.14-3.92). Specific intent to use medical cannabis to quit resulted in significantly greater odds of reducing T/N use (AOR = 2.79, 95% CI 1.49-5.22); however, involvement with traditional T/N cessation treatments (pharmacological or psychobehavioral) was negatively associated with T/N cessation (AOR 0.39, 95% CI 0.18-0.86). CONCLUSIONS Results from this retrospective survey of medical cannabis users suggest that initiation of medical cannabis use was associated with self-reported reductions and/or cessation of T/N use in nearly half of study participants. In light of the significant morbidity, mortality, and health care costs related to T/N dependence, future research should further evaluate the potential of cannabis-based treatments to support efforts to reduce or cease T/N use.
Collapse
Affiliation(s)
- Philippe Lucas
- Social Dimensions of Health, University of Victoria, 3800 Finnerty Rd., Victoria, BC V8P 5C2, Canada; Canadian Institute for Substance Use Research, 2300 McKenzie Ave., Victoria, BC V8N 5M8, Canada; Tilray, 1100 Maughan Rd., Nanaimo, BC V9X 1J2, Canada.
| | - Zach Walsh
- Department of Psychology, University of British Columbia, Okanagan, 3333 University Way, Kelowna, BC V1V 1V7, Canada; Centre for the Advancement of Psychological Science and Law, University of British Columbia, Okanagan, 3333 University Way, Kelowna, BC V1V 1V7, Canada.
| | - Peter S Hendricks
- Department of Health Behavior, School of Public Health, University of Alabama at Birmingham, 227L Ryals Public Health Building, 1665 University Blvd., Birmingham, AL 35294, USA.
| | - Susan Boyd
- Faculty of Human and Social Development, School of Public Health and Social Policy, University of Victoria, 3800 Finnerty Rd., Victoria, BC V8P 5C2, Canada.
| | - M-J Milloy
- Faculty of Medicine, University of British Columbia, St. Paul's Hospital 806-1081, Burrard St., Vancouver, BC, Canada; British Columbia Centre on Substance Use, 400-1045 Howe St., Vancouver, BC V6Z 2A9, Canada.
| |
Collapse
|
25
|
Matson TE, Carrell DS, Bobb JF, Cronkite DJ, Oliver MM, Luce C, Ghitza UE, Hsu CW, Campbell CI, Browne KC, Binswanger IA, Saxon AJ, Bradley KA, Lapham GT. Prevalence of Medical Cannabis Use and Associated Health Conditions Documented in Electronic Health Records Among Primary Care Patients in Washington State. JAMA Netw Open 2021; 4:e219375. [PMID: 33956129 PMCID: PMC8103224 DOI: 10.1001/jamanetworkopen.2021.9375] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 03/18/2021] [Indexed: 12/11/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Theresa E. Matson
- Kaiser Permanente Washington Health Research Institute, Seattle
- Department of Health Services, University of Washington, Seattle
| | | | | | | | - Malia M. Oliver
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Casey Luce
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Udi E. Ghitza
- Center for the Clinical Trials Network, National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland
| | - Clarissa W. Hsu
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Cynthia I. Campbell
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Kendall C. Browne
- Center of Excellence in Substance Addiction Treatment and Education, Veteran Affairs Puget Sound Health Care System, Seattle, Washington
| | - Ingrid A. Binswanger
- Kaiser Permanente Colorado Institute for Health Research and Colorado Permanente Medical Group, Denver
| | - Andrew J. Saxon
- Center of Excellence in Substance Addiction Treatment and Education, Veteran Affairs Puget Sound Health Care System, Seattle, Washington
| | - Katharine A. Bradley
- Kaiser Permanente Washington Health Research Institute, Seattle
- Department of Health Services, University of Washington, Seattle
| | - Gwen T. Lapham
- Kaiser Permanente Washington Health Research Institute, Seattle
- Department of Health Services, University of Washington, Seattle
| |
Collapse
|
26
|
Gorfinkel LR, Stohl M, Greenstein E, Aharonovich E, Olfson M, Hasin D. Is Cannabis being used as a substitute for non-medical opioids by adults with problem substance use in the United States? A within-person analysis. Addiction 2021; 116:1113-1121. [PMID: 33029914 PMCID: PMC8026758 DOI: 10.1111/add.15228] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 07/27/2020] [Accepted: 08/11/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Ecological studies have suggested that Cannabis legalization might have led to a decrease in opioid overdose deaths. Such studies do not provide information about whether individuals are substituting Cannabis for opioids at different points in time. The current study assessed the magnitude of the daily association between Cannabis and opioid use in individual adults with and without pain who use non-medical opioids. DESIGN Prospective cohort study. SETTING The greater New York area and a suburban inpatient addiction program. PARTICIPANTS Adults with problem substance use who use non-medical opioids, recruited from May 2016-June 2019. The analytical sample included 13 271 days of observation among 211 participants (64% male, 41% white, 78% unmarried, 80% unemployed, mean age 43 years). MEASUREMENTS Participants completed interviewer- and self-administered computerized surveys, and then responded to an interactive voice response (IVR) system daily for the following 90 days. The main exposures, Cannabis use and pain, were defined as responding affirmatively to the IVR question: 'Did you use Cannabis yesterday?' and endorsing moderate or severe pain at baseline, respectively. The main outcome, non-medical or illicit opioid use during 90-day follow-up, was defined as responding affirmatively to IVR question: 'Did you use heroin yesterday?' or 'Did you use prescription opioids more than prescribed or without a prescription yesterday?'. FINDINGS The mean IVR completion rate was 70%. The unadjusted odds ratio (aOR) indicating same-day use of Cannabis and opioids was 2.00 [95% confidence interval (CI) = 1.54-2.59]. Controlling for demographic characteristics, recruitment method, opioid types at baseline and pain, the aOR was 1.86 (95% CI = 1.44-2.41). A test of interaction between pain and Cannabis use to determine if the association of Cannabis with opioid use differed between people with moderate-to-severe pain and less-than-moderate pain was inconclusive. CONCLUSIONS Among US adults with problem substance use who use non-medical opioids, the odds of opioid use appear to be approximately doubled on days when Cannabis is used. This relationship does not appear to differ between people with moderate or more severe pain versus less than moderate pain, suggesting that Cannabis is not being used as a substitute for illegal opioids.
Collapse
Affiliation(s)
- Lauren R. Gorfinkel
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
- New York State Psychiatric Institute, New York, NY, USA
| | - Malki Stohl
- New York State Psychiatric Institute, New York, NY, USA
| | | | - Efrat Aharonovich
- Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Mark Olfson
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
- New York State Psychiatric Institute, New York, NY, USA
- Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Deborah Hasin
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
- New York State Psychiatric Institute, New York, NY, USA
- Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| |
Collapse
|
27
|
Victor B, Hager K, Stacy S. PerspectivesRe-legalizing cannabis for medical use in the USA. J Public Health (Oxf) 2021; 44:679-684. [PMID: 33823039 DOI: 10.1093/pubmed/fdab066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 01/23/2021] [Accepted: 02/18/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The purpose of this paper is to discuss the history of cannabis, its benefits, risks and the federal re-legalization of cannabis for medical use in the USA. METHODS Thirty-six states have legalized cannabis as a medicinal substance. Cannabis is a Schedule I drug, an illegal and controlled substance, making research on the substance challenging. Both the American Medical Association and the American Nurses Association have called for the re-scheduling of marijuana, so that research can be conducted, its benefits and risks discovered. RESULTS Data are demonstrating that medical marijuana may be beneficial as a step-down drug, decreasing the use of opioids and benzodiazepines, as well as deaths related to their overdose. Studies have indicated that cannabis is a low-risk substance, when compared to alcohol and opioids. There appear to be specific conditions in which cannabis provides relief of symptoms which no other medications can provide. There is also evidence of cannabis's negative effects on the developing brain. CONCLUSION Cannabis should be rescheduled and researched, so that its risks and benefits can be identified. Its medicinal use should be monitored, and its availability protected in children, pregnant women and pets.
Collapse
Affiliation(s)
- Brenda Victor
- Department of Medical Laboratory Science, Bellarmine University, Louisville, Kentucky 40205, USA
| | - Kathy Hager
- Bellarmine University, Lansing School of Nursing & Clinical Sciences, College of Health Professions, Louisville, Kentucky 40299, USA
| | - Shannon Stacy
- Alliance of Innovative Medicine, Goshen, Kentucky 40026, USA
| |
Collapse
|
28
|
Kaufman DE, Nihal AM, Leppo JD, Staples KM, McCall KL, Piper BJ. Opioid Mortality Following Implementation of Medical Cannabis Programs in the United States. PHARMACOPSYCHIATRY 2021; 54:91-95. [PMID: 33621991 DOI: 10.1055/a-1353-6509] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
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.
Collapse
Affiliation(s)
| | - Asawer M Nihal
- Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | - Janan D Leppo
- Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | - Kelly M Staples
- Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | | | - Brian J Piper
- Geisinger Commonwealth School of Medicine, Scranton, PA, USA.,Center for Pharmacy Innovation and Outcomes, Forty Fort, PA, USA
| |
Collapse
|
29
|
State Medical Cannabis Laws Associated With Reduction in Opioid Prescriptions by Orthopaedic Surgeons in Medicare Part D Cohort. J Am Acad Orthop Surg 2021; 29:e188-e197. [PMID: 32404683 DOI: 10.5435/jaaos-d-19-00767] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 04/07/2020] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Opioid prescriptions and abuse remain a significant national concern. Cannabinoids offer a potentially attractive nonopioid analgesic option for orthopaedic patients, and 32 US states have passed medical cannabis laws (MCLs), legalizing patient access to cannabinoids. We examine the association between implementation of state cannabis laws and prescribing patterns for opioids by orthopaedic surgeons in Medicare Part D patients between 2013 and 2017. METHODS Using the Medicare Part D Prescription Drug Event database, we measured annual aggregate daily doses of all opioid medications (excluding buprenorphine) prescribed by orthopaedic surgeons in each US state (and DC), in addition to total daily doses of opioid medications by generic name (hydrocodone, oxycodone, fentanyl, morphine, methadone, and "other opioids"). We used adjusted linear regression models to examine associations between state-specific cannabis regulations (state MCL, MCL type-dispensary or home cultivation, and recreational cannabis legalization) and annual total daily doses of opioid medications (all opioids and opioid types, separately). RESULTS State MCLs were associated with a statistically significant reduction in aggregate opioid prescribing of 144,000 daily doses (19.7% reduction) annually (95% confidence interval [CI], -0.535 to -0.024 million; P < 0.01). States with MCLs allowing access to in-state dispensaries had a statistically significant reduction in total opioid prescriptions of 96,000 daily doses (13.1%) annually (95% CI, -0.165 to -0.026 million; P < 0.01). Specifically, MCLs were associated with a statistically significant reduction of 72,000 daily doses of hydrocodone annually (95% CI, -0.164 to -0.019 million; P < 0.01). No significant association between recreational marijuana legalization and opioid prescribing was found. CONCLUSION Orthopaedic surgeons are among the highest prescribers of opioids, highlighting the importance of providing nonopioid analgesic alternatives in efforts to reduce opioid use in the patient cohort. This study is the first to examine the association between implementation of state cannabis laws and prescribing patterns for opioids by orthopaedic surgeons in Medicare Part D patients. LEVEL OF EVIDENCE Population-based ecological study.
Collapse
|
30
|
Jayawardhana J, Fernandez JM. The associations of medical marijuana policies with opioid-related health care utilization. Health Serv Res 2021; 56:299-309. [PMID: 33501701 DOI: 10.1111/1475-6773.13632] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To examine the associations between medical marijuana policies and opioid-related hospitalizations and emergency department visits. DATA SOURCES We utilized quarterly rates of hospital discharge data from the Healthcare Cost and Utilization Project's (HCUP) Fast Stats Database from 2005 to 2016 along with state-level sociodemographic data from US Census Bureau and Bureau of Labor Statistics and opioid-related state health policy data from publicly available sources for the analysis. STUDY DESIGN Analyses were carried out using a difference-in-differences regression approach. We estimate heterogeneous effects of medical marijuana policies such as initial policy, presence of active dispensary, and home cultivation on opioid-related hospitalizations and emergency department visits related to opioids. DATA COLLECTION/EXTRACTION METHODS Publicly available secondary data were collected, linked, and analyzed. Observations with missing values for explanatory variables were excluded from the analysis. PRINCIPAL FINDINGS Regression results indicate that type of medical marijuana policy has varying effects on opioid-related hospitalizations and emergency department visits. States that allow home cultivation of medical marijuana experienced significant positive associations with opioid-related hospitalizations and emergency department visits, while no effect was observed with medical marijuana dispensaries. Moreover, recreational marijuana policies were positively associated with opioid-related hospitalizations. CONCLUSIONS The findings indicate that the effects of medical marijuana policies on opioid-related hospitalizations and emergency department visits vary depending on the type of medical marijuana policy. Our findings indicate that the implementation of home cultivation of marijuana is positively associated with hospitalizations and emergency department visits related to opioids, suggesting that easier access to marijuana among opioid users may result in adverse health conditions that need treatment.
Collapse
Affiliation(s)
| | - Jose M Fernandez
- Department of Economics, University of Louisville, Louisville, Kentucky, USA
| |
Collapse
|
31
|
Boehnke KF, Litinas E, Worthing B, Conine L, Kruger DJ. Communication between healthcare providers and medical cannabis patients regarding referral and medication substitution. J Cannabis Res 2021; 3:2. [PMID: 33526140 PMCID: PMC7831240 DOI: 10.1186/s42238-021-00058-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 01/15/2021] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND People report using cannabis as a substitute for prescription medications but may be doing so without the knowledge of their primary health care providers (PCPs). This lack of integration creates serious concerns, e.g., using cannabis to treat medical conditions that have established treatment options. METHODS We conducted an anonymous, cross-sectional online survey among patrons of a medical cannabis dispensary in Michigan (n = 275) to examine aspects of their relationship with their PCP and their perceptions of PCP knowledge related to cannabis. RESULTS Overall, 64% of participants initiated medical cannabis use based on their own experiences vs. 24% citing advice from their PCP. Although 80% reported that their PCP knew they currently used medical cannabis, 41% reported that their PCP had not always known. Only 14% obtained their medical cannabis authorization from their PCP. Only 18% of participants rated their PCP's knowledge about medical cannabis as very good or excellent and only 21% were very or completely confident in their PCP's ability to integrate medical cannabis into their treatment. Although 86% had substituted cannabis for pharmaceutical medications, 69% (n = 134) of those who substituted reported some gap in their PCP's knowledge of their substitution, and 44% (n = 86) reported that their PCP was currently unaware of their substitution. CONCLUSIONS Patients frequently substitute cannabis for prescription drugs, often without PCP knowledge. Although most participants disclosed cannabis use to their PCP, their perceptions of PCP knowledge ranged widely and many obtained medical cannabis licensure from an outside physician. Our results highlight the need for standardized physician education around appropriate medical cannabis use.
Collapse
Affiliation(s)
- Kevin F Boehnke
- Anesthesiology Department, University of Michigan Medical School, 24 Frank Lloyd Wright Drive, Ann Arbor, MI, 48106, USA.
| | | | | | | | - Daniel J Kruger
- Population Studies Center, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
32
|
McGinty EE, Tormohlen KN, Barry CL, Bicket MC, Rutkow L, Stuart EA. Protocol: mixed-methods study of how implementation of US state medical cannabis laws affects treatment of chronic non-cancer pain and adverse opioid outcomes. Implement Sci 2021; 16:2. [PMID: 33413454 PMCID: PMC7789408 DOI: 10.1186/s13012-020-01071-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 12/04/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Thirty-three US states and Washington, D.C., have enacted medical cannabis laws allowing patients with chronic non-cancer pain to use cannabis, when recommended by a physician, to manage their condition. However, clinical guidelines do not recommend cannabis for treatment of chronic non-cancer pain due to limited and mixed evidence of effectiveness. How state medical cannabis laws affect delivery of evidence-based treatment for chronic non-cancer pain is unclear. These laws could lead to substitution of cannabis in place of clinical guideline-discordant opioid prescribing, reducing risk of opioid use disorder and overdose. Conversely, state medical cannabis laws could lead to substitution of cannabis in place of guideline-concordant treatments such as topical analgesics or physical therapy. This protocol describes a mixed-methods study examining the implementation and effects of state medical cannabis laws on treatment of chronic non-cancer pain. A key contribution of the study is the examination of how variation in state medical cannabis laws' policy implementation rules affects receipt of chronic non-cancer pain treatments. METHODS The study uses a concurrent-embedded design. The primary quantitative component of the study employs a difference-in-differences design using a policy trial emulation approach. Quantitative analyses will evaluate state medical cannabis laws' effects on treatment for chronic non-cancer pain as well as on receipt of treatment for opioid use disorder, opioid overdose, cannabis use disorder, and cannabis poisoning among people with chronic non-cancer pain. Secondary qualitative and survey methods will be used to characterize implementation of state medical cannabis laws through interviews with state leaders and representative surveys of physicians who treat, and patients who experience, chronic non-cancer pain in states with medical cannabis laws. DISCUSSION This study will examine the effects of medical cannabis laws on patients' receipt of guideline-concordant non-opioid, non-cannabis treatments for chronic non-cancer pain and generate new evidence on the effects of state medical cannabis laws on adverse opioid outcomes. Results will inform the dynamic policy environment in which numerous states consider, enact, and/or amend medical cannabis laws each year.
Collapse
|
33
|
Carrieri V, Madio L, Principe F. Do-It-Yourself medicine? The impact of light cannabis liberalization on prescription drugs. JOURNAL OF HEALTH ECONOMICS 2020; 74:102371. [PMID: 32920244 DOI: 10.1016/j.jhealeco.2020.102371] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 06/03/2020] [Accepted: 08/10/2020] [Indexed: 06/11/2023]
Abstract
Governments worldwide are increasingly concerned about the booming use of CBD (cannabidiol) products. However, we know little about the impact of their liberalization. We study a unique case of unintended liberalization of a CBD-based product (light cannabis) that occurred in Italy in 2017. Using unique and high-frequency data on prescription drug sales and by exploiting the staggered local availability of the new product in each Italian province, we document a significant substitution effect between light cannabis and anxiolytics, sedatives, opioids, anti-depressants and anti-psychotics. Results are informative for regulators and suggest that bans on light cannabis use would disregard the needs of patients to seek effective reliefs of their symptoms.
Collapse
Affiliation(s)
- Vincenzo Carrieri
- Department of Law, Economics and Sociology, "Magna Graecia" University, Catanzaro, Italy; Institute of Labor Economics (IZA), Bonn, Germany; RWI-Research Network, Essen, Germany.
| | - Leonardo Madio
- Toulouse School of Economics, Universitè Toulouse 1 Capitole, Toulouse, France; CESifo, Munich, Germany.
| | - Francesco Principe
- Erasmus School of Economics, Erasmus University Rotterdam, The Netherlands.
| |
Collapse
|
34
|
De Aquino JP, Sofuoglu M, Stefanovics EA, Rosenheck RA. Impact of cannabis on non-medical opioid use and symptoms of posttraumatic stress disorder: a nationwide longitudinal VA study. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2020; 46:812-822. [PMID: 33035104 DOI: 10.1080/00952990.2020.1818248] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Multiple states have authorized cannabis as an opioid substitution agent and as a treatment for posttraumatic stress disorder (PTSD). OBJECTIVES This study sought to investigate the relationship between cannabis use, non-medical opioid use, and PTSD symptoms among U.S. veterans. METHODS From 1992-2011, veterans admitted to specialized intensive PTSD treatment participated in a national evaluation with assessments at intake and four months after discharge. Participants with non-medical opioid use ≥ 7 days during the 30 days preceding admission were divided into two groups: those with cannabis use ≥ 7 days, and those without cannabis use. These two groups were compared on measures of substance use and PTSD symptoms at baseline and 4-months outpatient follow-up. We hypothesized that, at both assessments, the group with baseline cannabis use would show less non-medical opioid use and less severe PTSD symptoms. RESULTS Of 1,413 veterans with current non-medical opioid use, 438 (30.3%) also used cannabis, and 985 (69.7%) did not. At baseline, veterans with concurrent non-medical opioid and cannabis use had slightly fewer days of non-medical opioid use (p < .005; d = -0.16), greater use of other substances (p < .0001) and more PTSD symptoms (p = .003; d = 0.16), compared to veterans who used non-medical opioids but not cannabis. At follow-up, substance use or PTSD symptoms did not significantly differ. CONCLUSION Cannabis use was not associated with a substantial reduction of non-medical opioid use, or either improvement or worsening of PTSD symptoms in this population. Hence, these data do not encourage cannabis use to treat either non-medical opioid use or PTSD.
Collapse
Affiliation(s)
- Joao P De Aquino
- Department of Psychiatry, Yale School of Medicine , New Haven, CT, USA.,Mental Illness Research, Education and Clinical Centers, VA Connecticut Healthcare System , West Haven, CT, USA
| | - Mehmet Sofuoglu
- Department of Psychiatry, Yale School of Medicine , New Haven, CT, USA.,Mental Illness Research, Education and Clinical Centers, VA Connecticut Healthcare System , West Haven, CT, USA
| | - Elina A Stefanovics
- Department of Psychiatry, Yale School of Medicine , New Haven, CT, USA.,Mental Illness Research, Education and Clinical Centers, VA Connecticut Healthcare System , West Haven, CT, USA
| | - Robert A Rosenheck
- Department of Psychiatry, Yale School of Medicine , New Haven, CT, USA.,Mental Illness Research, Education and Clinical Centers, VA Connecticut Healthcare System , West Haven, CT, USA
| |
Collapse
|
35
|
McBain RK, Wong EC, Breslau J, Shearer AL, Cefalu MS, Roth E, Burnam MA, Collins RL. State medical marijuana laws, cannabis use and cannabis use disorder among adults with elevated psychological distress. Drug Alcohol Depend 2020; 215:108191. [PMID: 32736294 PMCID: PMC7502494 DOI: 10.1016/j.drugalcdep.2020.108191] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND Cannabis use and cannabis use disorder are more prevalent in U.S. states with medical marijuana laws (MMLs), as well as among individuals with elevated psychological distress. We investigated whether adults with moderate and serious psychological distress experienced greater levels of cannabis use and/or disorder in states with MMLs compared to states without MMLs. METHODS National Survey of Drug Use and Health data (2013-2017) were used to compare past-month cannabis use, daily cannabis use, and cannabis use disorder prevalence among adults with moderate and serious psychological distress in states with versus without MMLs. We executed pooled multivariable logistic regression analyses to test main effects of distress, MMLs and their interaction, after adjustment. RESULTS Compared to states without MMLs, states with MMLs had higher adjusted prevalence of past-month use (11.1 % vs. 6.8 %), daily use (4.0 % vs. 2.2 %), and disorder (1.7 % vs. 1.2 %). Adults with moderate and serious psychological distress had greater adjusted odds of any use (AORs of 1.72 and 2.22, respectively) and of disorder (AORs of 2.17 and 2.94, respectively), compared to those with no/mild distress. We did not find evidence of an interaction between MMLs and distress category for any outcome. CONCLUSIONS Associations between elevated distress and cannabis use patterns are no greater in states with MML. However, cannabis use is more prevalent in MML states. Thus, higher base rates of cannabis use and disorder among adults with elevated distress are proportionally magnified in these states.
Collapse
Affiliation(s)
- Ryan K McBain
- RAND Corporation, 20 Park Plz, Boston, MA, 02116, USA.
| | - Eunice C Wong
- RAND Corporation, 1776 Main St, Santa Monica, CA 90407 USA
| | - Joshua Breslau
- RAND Corporation, 4570 Fifth St, Pittsburgh, PA 15213 USA
| | - Amy L Shearer
- RAND Corporation, 1776 Main St, Santa Monica, CA 90407 USA
| | | | - Elizabeth Roth
- RAND Corporation, 1776 Main St, Santa Monica, CA 90407 USA
| | | | | |
Collapse
|
36
|
Scheim AI, Maghsoudi N, Marshall Z, Churchill S, Ziegler C, Werb D. Impact evaluations of drug decriminalisation and legal regulation on drug use, health and social harms: a systematic review. BMJ Open 2020; 10:e035148. [PMID: 32958480 PMCID: PMC7507857 DOI: 10.1136/bmjopen-2019-035148] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES To review the metrics and findings of studies evaluating effects of drug decriminalisation or legal regulation on drug availability, use or related health and social harms globally. DESIGN Systematic review with narrative synthesis. DATA SOURCES We searched MEDLINE, Embase, PsycINFO, Web of Science and six additional databases for publications from 1 January 1970 through 4 October 2018. INCLUSION CRITERIA Peer-reviewed articles or published abstracts in any language with quantitative data on drug availability, use or related health and social harms collected before and after implementation of de jure drug decriminalisation or legal regulation. DATA EXTRACTION AND SYNTHESIS Two independent reviewers screened titles, abstracts and articles for inclusion. Extraction and quality appraisal (modified Downs and Black checklist) were performed by one reviewer and checked by a second, with discrepancies resolved by a third. We coded study-level outcome measures into metric groupings and categorised the estimated direction of association between the legal change and outcomes of interest. RESULTS We screened 4860 titles and 221 full-texts and included 114 articles. Most (n=104, 91.2%) were from the USA, evaluated cannabis reform (n=109, 95.6%) and focussed on legal regulation (n=96, 84.2%). 224 study outcome measures were categorised into 32 metrics, most commonly prevalence (39.5% of studies), frequency (14.0%) or perceived harmfulness (10.5%) of use of the decriminalised or regulated drug; or use of tobacco, alcohol or other drugs (12.3%). Across all substance use metrics, legal reform was most often not associated with changes in use. CONCLUSIONS Studies evaluating drug decriminalisation and legal regulation are concentrated in the USA and on cannabis legalisation. Despite the range of outcomes potentially impacted by drug law reform, extant research is narrowly focussed, with a particular emphasis on the prevalence of use. Metrics in drug law reform evaluations require improved alignment with relevant health and social outcomes.
Collapse
Affiliation(s)
- Ayden I Scheim
- Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania, USA
- Centre on Drug Policy Evaluation, St Michael's Hospital, Toronto, Ontario, Canada
| | - Nazlee Maghsoudi
- Centre on Drug Policy Evaluation, St Michael's Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Zack Marshall
- Social Work, McGill University, Montreal, Quebec, Canada
| | - Siobhan Churchill
- Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Carolyn Ziegler
- Library Services, Unity Health Toronto, Toronto, Ontario, Canada
| | - Dan Werb
- Centre on Drug Policy Evaluation, St Michael's Hospital, Toronto, Ontario, Canada
- Medicine, University of California San Diego, La Jolla, California, USA
| |
Collapse
|
37
|
Ramadan MM, Banta JE, Bahjri K, Montgomery SB. Marijuana users are likely to report opioid misuse among adults over 50 years in representative sample of the United States (2002-2014). J Addict Dis 2020; 39:66-73. [PMID: 32935646 DOI: 10.1080/10550887.2020.1816117] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Background: In the wake of the rising rate of prescription opioid misuse, there has been increased public health interest in the possibility that cannabis might help to curb or prevent opioid use disorder. Previous studies were limited to young adult marijuana use population. Little is known about whether in older adult population, marijuana use is associated with a different type of nonmedical use opioids. We examined the association between marijuana use and nonmedical prescription opioids dependence and use among older adults.Methods: The National Survey on Drug Use and Health is a nationally U.S. representative cross-sectional survey. We analyzed data for 75,949 adults aged ≥ 50 who participated in the year 2002-2014.Results: Within the overall population, 3.8% of the older adults reported past-year marijuana use (estimate 3.5 million older adults Americans). Past-year marijuana use was very common (25%-37%) among nonmedical opioid dependence respondents compared to those who did not report nonmedical opioid dependence and use (3.5%-3.7%). Past-year marijuana user was significantly associated with an increase in odds of reporting opioid dependence (AOR 9.6 95% CI = 5.8-15.7), and past-year nonmedical use opioids (AOR 6.4 95% CI = 5.2-7.8). Illicit drug heroin was the most prevalent nonmedical used opioid (AOR 6.3 95% CI = 5.0-7.9), compared to codeine (AOR 4.5 95% CI = 3.5-5.7), hydrocodone (AOR 4.9 95% CI = 3.8-6.4), methadone or tramadol (AOR 4.9 95% CI = 2.0-12.3).Conclusion: Policymakers and healthcare providers should remain mindful that older adult marijuana users regardless of initial legitimate medical needs are likely to report nonmedical opioid use including illicit drug heroin.
Collapse
Affiliation(s)
- Majed M Ramadan
- Department of Health Policy and Leadership, School of Public Health, University of Loma Linda, Loma Linda, CA, USA
| | - Jim E Banta
- School of Public Health, Center for Leadership in Health Systems, Loma Linda University, Loma Linda, CA, USA
| | - Khaled Bahjri
- School of Pharmacy, Loma Linda University, Loma Linda, CA, USA
| | - Susanne B Montgomery
- Loma Linda University School of Behavioral Health, Loma Linda, CA, USA.,Behavioral Health Institute, Loma Linda University, Loma Linda, CA, USA
| |
Collapse
|
38
|
Boehnke KF, Gangopadhyay S, Clauw DJ, Haffajee RL. Qualifying Conditions Of Medical Cannabis License Holders In The United States. Health Aff (Millwood) 2020; 38:295-302. [PMID: 30715980 DOI: 10.1377/hlthaff.2018.05266] [Citation(s) in RCA: 121] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
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.
Collapse
Affiliation(s)
- Kevin F Boehnke
- Kevin F. Boehnke ( ) is a research investigator in anesthesiology at the University of Michigan, in Ann Arbor
| | | | - Daniel J Clauw
- Daniel J. Clauw is a professor of anesthesiology, medicine, and psychiatry at the University of Michigan Medical School, in Ann Arbor
| | - Rebecca L Haffajee
- Rebecca L. Haffajee is an assistant professor of health management and policy, University of Michigan School of Public Health, in Ann Arbor
| |
Collapse
|
39
|
Conyers G, Ayres I. A lottery test of the effect of dispensaries on emergency room visits in Arizona. HEALTH ECONOMICS 2020; 29:854-864. [PMID: 32548868 DOI: 10.1002/hec.4013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 02/02/2020] [Accepted: 02/10/2020] [Indexed: 06/11/2023]
Abstract
In August 2012, the Arizona Department of Health Services conducted a lottery to allocate licenses for the state's first medical marijuana dispensaries. The lottery randomly selected an applicant within each of 69 contested Community Health Analysis Areas to open a dispensary. By comparing 36 zip codes with winning applications to 48 zip codes with losing applications and weighting using propensity scores based on the true probability of winning, we estimate the causal effect of the allocation of a dispensary on the emergency room visits of residents of that zip code. Outcomes of interest are emergency room visits for acute symptoms caused by cannabis, opioids, alcohol, and cocaine. Using emergency room discharge data from 2010 to 2016, we find evidence of an increase in visits for acute cannabis-related causes for the winning set of zip codes and weak evidence of an increase in visits for opioid-related causes. The results indicate that in the four years following the lottery, emergency room visits for acute cannabis causes rose by approximately 45% in allocated zip codes relative to non-allocated zip codes. Because of the high likelihood of spillovers to neighboring zip codes, these effects are likely underestimates.
Collapse
Affiliation(s)
| | - Ian Ayres
- Yale Law School, Yale University, New Haven, Connecticut
| |
Collapse
|
40
|
Hasin DS, Shmulewitz D, Cerdá M, Keyes KM, Olfson M, Sarvet AL, Wall MM. U.S. Adults With Pain, a Group Increasingly Vulnerable to Nonmedical Cannabis Use and Cannabis Use Disorder: 2001-2002 and 2012-2013. Am J Psychiatry 2020; 177:611-618. [PMID: 31964162 PMCID: PMC7332392 DOI: 10.1176/appi.ajp.2019.19030284] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Given changes in U.S. marijuana laws, attitudes, and use patterns, individuals with pain may be an emerging group at risk for nonmedical cannabis use and cannabis use disorder. The authors examined differences in the prevalence of nonmedical cannabis use and cannabis use disorder among U.S. adults with and without pain, as well as whether these differences widened over time. METHODS Data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC, 2001-2002; N=43,093) and NESARC-III (2012-2013; N=36,309) were analyzed using logistic regression. Risk differences of past-year nonmedical cannabis use, frequent (at least three times a week) nonmedical use, and DSM-IV cannabis use disorder were estimated for groups with and without moderate to severe pain, and these risk differences were tested for change over time. RESULTS Any nonmedical cannabis use was more prevalent in respondents with than without pain (2001-2002: 5.15% compared with 3.74%; 2012-2013: 12.42% compared with 9.02%), a risk difference significantly greater in the 2012-2013 data than in the 2001-2002 data. The prevalence of frequent nonmedical cannabis use did not differ by pain status in the 2001-2002 survey, but was significantly more prevalent in those with than without pain in the 2012-2013 survey (5.03% compared with 3.45%). Cannabis use disorder was more prevalent in respondents with than without pain (2001-2002: 1.77% compared with 1.35%; 2012-2013: 4.18% compared with 2.74%), a significantly greater risk difference in the data from 2012-2013 than from 2001-2002. CONCLUSIONS The results suggest that adults with pain are a group increasingly vulnerable to adverse cannabis use outcomes, warranting clinical and public health attention to this risk. Psychiatrists and other health care providers treating patients with pain should monitor such patients for signs and symptoms of cannabis use disorder.
Collapse
Affiliation(s)
- Deborah S. Hasin
- NewYork State Psychiatric Institute, NewYork; Department of Psychiatry, Columbia University Medical Center, New York; Department of Epidemiology, Columbia University Mailman School of Public Health, New York
| | - Dvora Shmulewitz
- NewYork State Psychiatric Institute, New York; Department of Psychiatry, Columbia University Medical Center, New York; Department of Epidemiology, Columbia University Mailman School of Public Health, New York
| | - Magdalena Cerdá
- Columbia University Mailman School of Public Health, New York; Department of Population Health, New York University, New York
| | - Katherine M. Keyes
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York
| | - Mark Olfson
- NewYork State Psychiatric Institute, New York; Department of Psychiatry, Columbia University Medical Center, New York, Department of Epidemiology
| | - Aaron L. Sarvet
- Department of Epidemiology, Harvard University School of Public Health, Boston
| | - Melanie M. Wall
- NewYork State Psychiatric Institute, New York; Department of Psychiatry, Columbia University Medical Center, New York; Department of Biostatistics
| |
Collapse
|
41
|
Prescription Opioid Distribution after the Legalization of Recreational Marijuana in Colorado. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17093251. [PMID: 32392702 PMCID: PMC7246665 DOI: 10.3390/ijerph17093251] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 04/23/2020] [Accepted: 04/25/2020] [Indexed: 12/11/2022]
Abstract
There have been dynamic changes in prescription opioid use in the US but the state level policy factors contributing to these are incompletely understood. We examined the association between the legalization of recreational marijuana and prescription opioid distribution in Colorado. Utah and Maryland, two states that had not legalized recreational marijuana, were selected for comparison. Prescription data reported to the Drug Enforcement Administration for nine opioids used for pain (e.g., fentanyl, morphine, hydrocodone, hydromorphone, oxycodone, oxymorphone) and two primarily for opioid use disorder (OUD, methadone and buprenorphine) from 2007 to 2017 were evaluated. Analysis of the interval pre (2007-2012) versus post (2013-2017) marijuana legalization revealed statistically significant decreases for Colorado (P < 0.05) and Maryland (P < 0.01), but not Utah, for pain medications. There was a larger reduction from 2012 to 2017 in Colorado (-31.5%) than the other states (-14.2% to -23.5%). Colorado had a significantly greater decrease in codeine and oxymorphone than the comparison states. The most prevalent opioids by morphine equivalents were oxycodone and methadone. Due to rapid and pronounced changes in prescription opioid distribution over the past decade, additional study with more states is needed to determine whether cannabis policy was associated with reductions in opioids used for chronic pain.
Collapse
|
42
|
Ghimire KM, Maclean JC. Medical marijuana and workers' compensation claiming. HEALTH ECONOMICS 2020; 29:419-434. [PMID: 32020740 DOI: 10.1002/hec.3992] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 12/01/2019] [Accepted: 12/04/2019] [Indexed: 06/10/2023]
Abstract
We study the effect of state medical marijuana laws (MMLs) on workers' compensation (WC) claiming among adults. Medical marijuana is plausibly related to WC claiming by allowing improved symptom management, and thus reduced need for the benefit, among injured or ill workers. We use data on claiming drawn from the Annual Social and Economic supplement to the Current Population Survey over the period 1989 to 2012, coupled with a differences-in-differences design to provide the first evidence on this relationship. Our estimates show that, post MML, WC claiming declines, both the propensity to claim and the level of income from WC. These findings suggest that medical marijuana can allow workers to better manage symptoms associated with workplace injuries and illnesses and, in turn, reduce need for WC. However, the reductions in WC claiming post MML are very modest in size.
Collapse
Affiliation(s)
- Keshar M Ghimire
- Business and Economics Department, University of Cincinnati Blue Ash College, Blue Ash, Ohio
| | | |
Collapse
|
43
|
Hayat A, Piper BJ. Characteristics of Dispensary Patients that Limit Alcohol after Initiating Cannabis. J Psychoactive Drugs 2020; 52:145-152. [PMID: 31813342 PMCID: PMC7275884 DOI: 10.1080/02791072.2019.1694199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 07/31/2019] [Accepted: 09/23/2019] [Indexed: 12/21/2022]
Abstract
Many patients have reported that they decrease their use of opioids after starting medical cannabis (MC) but less is known for alcohol. The objective of this exploratory study was to identify any factors which differentiate alcohol abaters from those that do not modify their alcohol use after starting MC (non-abaters). Comparisons were made to identify any demographic, dosing, or health history characteristics which differentiated alcohol abaters (N = 47) from non-abaters (N = 65). Respondents selected from among a list of 37 diseases/health conditions (e.g. diabetes, sleep disorders). Abaters and non-abaters were indistinguishable in terms of sex, age, or prior drug history. A greater percentage of abaters (59.6%) than non-abaters (40.6%, p < .05) reported using MC two or more times per day. Abaters were more likely to be employed (68.1%) than non-abaters (51.1%, p < .05). Abaters also reported having significantly more health conditions and diseases (3.3 ± 2.0) than non-abaters (2.4 ± 1.4, p < .05). This small study offers some insights into the profile of patients whose self-reported alcohol intake decreased following initiation of MC. Additional prospective or controlled research into the alcohol abatement phenomenon following MC may be warranted.
Collapse
Affiliation(s)
- Assad Hayat
- Geisinger Commonwealth School of Medicine, Scranton, PA 18509 USA
| | - Brian J. Piper
- Geisinger Commonwealth School of Medicine, Scranton, PA 18509 USA
- Center for Pharmacy Innovation and Outcomes, Geisinger Precision Health Center, Forty Fort, PA 18704 USA
- Neuroscience Program, Bowdoin College, Brunswick, ME 04011 USA
| |
Collapse
|
44
|
Does Medical Cannabis Use Increase or Decrease the Use of Opioid Analgesics and Other Prescription Drugs? J Addict Med 2020; 12:259-261. [PMID: 29664894 DOI: 10.1097/adm.0000000000000404] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
: In observational and retrospective studies, people who use cannabis are more likely than people who do not use cannabis to also use other drugs. People who take medical cannabis are also more likely to report medical and non-medical use of opioid analgesics, stimulants, and tranquilizers. Given that people who take medical cannabis and those who do not are likely to have different underlying morbidity, it is possible that medical cannabis use reduces prescription drug use yet prescription drug use remains relatively high. Studies comparing people who take medical cannabis with people who do not take it cannot draw conclusions about the effect of medical cannabis on drug use. To fully understand the effect of medical cannabis on the use of other drugs, prospective longitudinal studies randomizing individuals to cannabis versus other treatments are urgently needed.
Collapse
|
45
|
Li G, Chihuri S. Is marijuana use associated with decreased use of prescription opioids? Toxicological findings from two US national samples of drivers. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2020; 15:12. [PMID: 32066484 PMCID: PMC7027272 DOI: 10.1186/s13011-020-00257-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 02/10/2020] [Indexed: 11/10/2022]
Abstract
Background State governments in the United States are increasingly viewing marijuana legalization as a policy option for controlling the opioid epidemic under the premise that marijuana is a less harmful substitute for opioids. The purpose of this study is to assess whether marijuana use is associated with decreased odds of prescription opioid use. Methods A cross-sectional study design was applied to toxicological testing data from two national samples of drivers: 1) the 2011–2016 Fatality Analysis Reporting System (FARS) and 2) the 2013–2014 National Roadside Survey of Alcohol and Drug Use by Drivers (NRS). Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) estimated from multivariable logistic regression models were used to assess the associations of marijuana use with prescription opioid use and alcohol use. Results Among the 47,602 drivers from the FARS, 15.7% tested positive for marijuana and 6.9% positive for prescription opioids. Compared with drivers testing negative for marijuana, those testing positive for marijuana were 28% more likely to test positive for prescription opioids (adjusted OR = 1.28, 95% CI = 1.15–1.42). Among the 7881 drivers from the NRS, 7.9% tested positive for marijuana and 4.5% positive for prescription opioids. Relative to drivers testing negative for marijuana, those testing positive for marijuana were twice as likely to test positive for prescription opioids (adjusted OR = 2.03, 95% CI = 1.29–3.20). In both study samples, marijuana use was associated with significantly increased odds of alcohol positivity. Conclusions Drivers who test positive for marijuana are significantly more likely to test positive for prescription opioids. Longitudinal studies with rigorous designs and toxicological testing data are needed to further address the substitution hypothesis between marijuana and prescription opioids.
Collapse
Affiliation(s)
- Guohua Li
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, 622 West 168th St, PH5-505, New York, NY, 10032, USA. .,Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA.
| | - Stanford Chihuri
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, 622 West 168th St, PH5-505, New York, NY, 10032, USA
| |
Collapse
|
46
|
McMichael BJ, Van Horn RL, Viscusi WK. The impact of cannabis access laws on opioid prescribing. JOURNAL OF HEALTH ECONOMICS 2020; 69:102273. [PMID: 31865260 DOI: 10.1016/j.jhealeco.2019.102273] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 07/17/2019] [Accepted: 12/07/2019] [Indexed: 05/28/2023]
Abstract
While recent research has shown that cannabis access laws can reduce the use of prescription opioids, the effect of these laws on opioid use is not well understood for all dimensions of use and for the general United States population. Analyzing a dataset of over 1.5 billion individual opioid prescriptions between 2011 and 2018, which were aggregated to the individual provider-year level, we find that recreational and medical cannabis access laws reduce the number of morphine milligram equivalents prescribed each year by 11.8 and 4.2 percent, respectively. These laws also reduce the total days' supply of opioids prescribed, the total number of patients receiving opioids, and the probability a provider prescribes any opioids net of any offsetting effects. Additionally, we find consistent evidence that cannabis access laws have different effects across types of providers, physician specialties, and payers.
Collapse
Affiliation(s)
- Benjamin J McMichael
- Assistant Professor of Law, University of Alabama School of Law, Box 870382, 101 Paul W. Bryant Drive East, Tuscaloosa, AL, 35487, United States.
| | - R Lawrence Van Horn
- Associate Professor of Management and Law, Executive Director of Health Affairs, Owen Graduate School of Management, Vanderbilt University, 401 21st Avenue South, Nashville, TN, 37203, United States.
| | - W Kip Viscusi
- University Distinguished Professor of Law, Economics, and Management, Vanderbilt University Law School. 131 21st Avenue South, Nashville, TN, 37203, United States.
| |
Collapse
|
47
|
Liang D, Shi Y. The association between pain clinic laws and prescription opioid exposures: New evidence from multi-state comparisons. Drug Alcohol Depend 2020; 206:107754. [PMID: 31786399 PMCID: PMC6980704 DOI: 10.1016/j.drugalcdep.2019.107754] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 11/15/2019] [Accepted: 11/19/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVES States in the US are controlling opioid prescribing to combat the opioid epidemic. Prescription Drug Monitoring Programs (PDMPs) were widely adopted, whereas less attention was given to pain clinic laws. This study examined the associations of mandatory use of PDMPs and pain clinic laws with prescription opioid exposures. METHODS State-level quarterly prescription opioid exposures reported to the National Poison Data System during 2010-2017 were analyzed. The primary outcome was age-adjusted rates of prescription opioid exposures per 1,000,000 population. The primary policy variables included the implementation of mandatory use of PDMPs alone, the implementation of pain clinic laws alone, and the implementation of both mandatory use of PDMPs and pain clinic laws. Linear regressions were used to examine the associations, controlling for other opioid policies, marijuana policies, socioeconomic factors, state fixed effects, time fixed effects, and state-specific time trends. RESULTS Requiring mandatory use of PDMPs alone was not associated with significant changes in prescription opioid exposures. The implementation of pain clinic laws with or without concurrent mandatory use of PDMPs was associated with 5 fewer prescription opioid exposures per 1,000,000 population or a 9 % reduction compared to the pre-policy period (p < 0.01). Further analysis revealed that the reduction associated with pain clinic laws was pronounced in exposures reported by healthcare facilities. CONCLUSIONS This multi-state study provided new evidence that the implementation of pain clinic laws was associated with a significant reduction in prescription opioid exposures. Pain clinic laws may deserve further evaluation and consideration.
Collapse
Affiliation(s)
- Di Liang
- Department of Family Medicine and Public Health, University of California San Diego, CA, USA; School of Public Health, Fudan University, Shanghai, China
| | - Yuyan Shi
- Department of Family Medicine and Public Health, University of California San Diego, CA, USA.
| |
Collapse
|
48
|
Kansagara D, Becker WC, Ayers C, Tetrault JM. Priming primary care providers to engage in evidence-based discussions about cannabis with patients. Addict Sci Clin Pract 2019; 14:42. [PMID: 31787111 PMCID: PMC6886188 DOI: 10.1186/s13722-019-0171-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 11/09/2019] [Indexed: 12/17/2022] Open
Abstract
Cannabis use has become increasingly common in the U.S. in recent years, with legalization for medical and recreational purposes expanding to more states. With this increase in use and access, providers should be prepared to have more conversations with patients about use. This review provides an overview of cannabis terminology, pharmacology, benefits, harms, and risk mitigation strategies to help providers engage in these discussions with their patients. Current evidence for the medical use of cannabis, cannabis-related diagnoses including cannabis use disorder (CUD) and withdrawal syndromes, and the co-use of opioids and cannabis are discussed. It is crucial that providers have the tools and information they need to deliver consistent, evidence-based assessment, treatment, prevention and harm-reduction, and we offer practical guidance in these areas.
Collapse
Affiliation(s)
- Devan Kansagara
- VA Evidence Synthesis Program, VA Portland Healthcare System, Mail Code R&D 71, 3710 SW US Veterans Hospital Road, Portland, OR 97239-2999 USA
- Oregon Health & Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239 USA
| | - William C. Becker
- Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510 USA
- VA Connecticut Healthcare System, West Haven, CT 06516 USA
| | - Chelsea Ayers
- VA Evidence Synthesis Program, VA Portland Healthcare System, Mail Code R&D 71, 3710 SW US Veterans Hospital Road, Portland, OR 97239-2999 USA
| | - Jeanette M. Tetrault
- Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510 USA
| |
Collapse
|
49
|
Cooper ZD, Adinoff B. Necessity of addressing motivations for cannabis use to guide research. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2019; 45:547-550. [PMID: 31755836 DOI: 10.1080/00952990.2019.1680991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Ziva D Cooper
- UCLA Cannabis Research Initiative, Jane and Terry Semel Institute for Neuroscience and Human Behavior, Department of Psychiatry and Biobehavioral Science, University of California, Los Angeles, CA, USA.,Department of Psychiatry, Columbia University Medical Center and New York State Psychiatric Institute, New York, NY, USA
| | - Bryon Adinoff
- Department of Psychiatry, University of Colorado School of Medicine, Denver, CO, USA
| |
Collapse
|
50
|
Trends in Opioid Misuse among Marijuana Users and Non-Users in the U.S. from 2007-2017. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16224585. [PMID: 31752436 PMCID: PMC6888158 DOI: 10.3390/ijerph16224585] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 11/15/2019] [Accepted: 11/16/2019] [Indexed: 01/03/2023]
Abstract
Prescription-opioid misus e continues to be a significant health concern in the United States. The relationship between marijuana use and prescription-opioid misuse is not clear from the extant literature. This study examined national trends in prescription-opioid misuse among marijuana users and non-users using the 2007-2017 National Survey on Drug Use and Health. Cochran-Armitage tests were used to assess the statistical significance of changes in the yearly prevalence of prescription-opioid misuse and marijuana use. Multivariable logistic regression was used to examine the association between prescription-opioid and marijuana use adjusting for sociodemographic characteristics. From 2007 to 2017, marijuana use increased, while prescription-opioid misuse declined. Larger declines in prescription-opioid misuse were found among marijuana users than non-users. Marijuana ever-use was significantly associated with prescription-opioid misuse. Specifically, marijuana ever-users had higher odds of prescription-opioid misuse (ever-misuse [OR: 3.04; 95% CI, 2.68-3.43]; past-year misuse [OR: 3.44; 95% CI, 3.00-3.94]; and past-month misuse [OR: 4.50; 95% CI, 3.35-6.05]) compared to marijuana never-users. Similar results were found for the association of past-year and past-month marijuana use with prescription-opioid misuse. This study provides data on trends and associations about opioid misuse among marijuana users and non-users in a changing social environment of drug use in the United States. Future research should consider whether there is a causal relationship between marijuana use and prescription opioid misuse.
Collapse
|