Association of US Medical Marijuana Laws With Nonmedical Prescription Opioid Use and Prescription Opioid Use Disorder

Does cannabis use substitute for opioids? A preliminary exploratory survey in opioid maintenance patients

Various studies showed that people with substance use disorder use cannabis to reduce withdrawal or dose of their main drug. Using a questionnaire about their cannabis use, 118 participants in an opioid maintenance treatment (OMT) in Germany were examined regarding this strategy. 60% reported to use cannabis. Of those, 72% were using cannabis in the suggested way. Cannabis was used to substitute for, e.g., heroin (44.8%) and benzodiazepines (16.4%). We also asked for an estimation of how good cannabis was able to substitute for several substances (in German school grades (1 till 6)); heroin average grade: 2.6 ± 1.49. Besides that we asked about the idea of cannabis as "self-medication", e.g., to reduce pain (47%) and about negative consequences from cannabis use. Our results suggest to consider the use of cannabis by patients in OMT rather as a harm reduction strategy to reduce the intake of more dangerous drugs.

United States marijuana legalization and opioid mortality trends before and during the first year of the COVID-19 pandemic

BACKGROUND

To determine if marijuana legalization was associated with reduced opioid mortality.

STUDY DESIGN

The United States (US) opioid mortality trend during the 2010-2019 decade was compared in states and District of Columbia (jurisdictions) that had implemented marijuana legalization with states that had not. Acceleration of opioid mortality during 2020, the first year of the coronavirus disease 2019 (COVID-19) pandemic, was also compared in recreational and medicinal-only legalizing jurisdictions.

METHODS

Joinpoint methodology was applied to the Centers for Disease Control and Prevention WONDER data. Trends in legalizing jurisdictions were cumulative aggregates.

RESULTS

The overall opioid and fentanyl death rates and the percentage of opioid deaths due to fentanyl increased more during 2010-2019 in jurisdictions that legalized marijuana than in those that did not (pairwise comparison p = 0.007, 0.05, and 0.006, respectively). By 2019, the all-opioid and fentanyl death rates were 44 and 50 percent greater in the legalizing than in the nonlegalizing jurisdictions, respectively. When the COVID-19 pandemic hit in 2020, jurisdictions that implemented recreational marijuana legalization before 2019 had significantly greater increases in both overall opioid and fentanyl death rates than jurisdictions with medicinal-only legalization. For all-opioids, the mean (95 percent confidence interval) 2019-to-2020 increases were 46.5 percent (36.6, 56.3 percent) and 29.1 percent (20.2, 37.9 percent), respectively (p = 0.02). For fentanyl, they were 115.6 percent (80.2, 151.6 percent) and 55.4 percent (31.6, 79.2 percent), respectively (p = 0.01).

CONCLUSIONS

During the past decade, marijuana legalization in the US was associated at the jurisdiction level with a greater acceleration in opioid death rate. An even greater increase in opioid mortality occurred in recreational-legalizing jurisdictions with the onset of the COVID-19 pandemic. Marijuana legalization is correlated with worsening of the US opioid epidemic.

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

Background

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

Objectives

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

Search Methods

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

Selection Criteria

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

Data Collection and Analysis

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

Main Results

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

Authors’ Conclusions

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

Medical marijuana access and prolonged opioid use among adolescents and young adults

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.

Recreational cannabis legislation and binge drinking in U.S. adolescents and adults

BACKGROUND

Recreational cannabis laws (RCLs) may have spillover effects on binge drinking. Our aims were to investigate binge drinking time trends and the association between RCLs and changes in binge drinking in the United States (U.S.).

METHODS

We used restricted National Survey on Drug Use and Health data (2008-2019). We examined trends in the prevalence of past-month binge drinking by age groups (12-20, 21-30, 31-40, 41-50, 51+). Then, we compared model-based prevalences of past-month binge drinking before and after RCL by age group, using multi-level logistic regression with state random intercepts, an RCL by age group interaction term, and controlling for state alcohol policies.

RESULTS

Binge drinking declined overall from 2008 to 2019 among people aged 12-20 (17.54% to 11.08%), and those aged 21-30 (43.66% to 40.22%). However, binge drinking increased among people aged 31+ (ages 31-40: 28.11% to 33.34%, ages 41-50: 25.48% to 28.32%, ages 51+: 13.28% to 16.75%). When investigating model-based prevalences after versus before RCL, binge drinking decreased among people aged 12-20 (prevalence difference=-4.8%; adjusted odds ratio (aOR)=0.77, [95% confidence interval (CI) 0.70-0.85]), and increased among participants aged 31-40 (+1.7%; 1.09[1.01-1.26]), 41-50 (+2.5; 1.15[1.05-1.26]) and 51+ (+1.8%; 1.17[1.06-1.30]). No RCL-related changes were noted in respondents ages 21-30.

CONCLUSIONS

Implementation of RCLs was associated with increased past-month binge drinking in adults aged 31+ and decreased past-month binge drinking in those aged < 21. As the cannabis legislative landscape continues to change in the U.S., efforts to minimize harms related to binge drinking are critical.

Cannabis Recreational Legalization and Prevalence of Simultaneous Cannabis and Alcohol Use in the United States

BACKGROUND

Simultaneous cannabis/alcohol use, using both substances within a short time interval so that their effects overlap, has a greater risk of potential negative consequences than single-substance use and is more common in younger age. Relationships between recreational cannabis laws (RCLs) and changes in simultaneous cannabis/alcohol use prevalence remain untested.

OBJECTIVE

To examine trends in simultaneous cannabis/alcohol use from 2008 to 2019, and investigate associations between implementation of RCLs (i.e., presence of active legal dispensaries or legal home cultivation) and simultaneous cannabis/alcohol use in the United States (U.S.).

DESIGN

Repeated cross-sectional samples from the 2008-2019 U.S. National Survey on Drug Use and Health (NSDUH).

PARTICIPANTS

Respondents (51% female) aged 12 and older.

INTERVENTIONS

Changes in simultaneous cannabis/alcohol use before and after RCL implementation (controlling for medical cannabis law implementation) were compared in different age groups (12-20, 21-30, 31-40, 41-50, 51+), using adjusted multi-level logistic regression with state random intercepts and an RCL/age group interaction.

MEASUREMENTS

Self-reported simultaneous cannabis/alcohol use.

RESULTS

From 2008 to 2019, the overall prevalence of simultaneous cannabis/alcohol use declined among those aged 12-20 but increased in adults aged 21+. Model-based simultaneous cannabis/alcohol use prevalence increased after RCL implementation among respondents aged 21-30 years (+1.2%; aOR= 1.15 [95%CI = 1.04-1.27]), 31-40 years (+1.0; 1.15 [1.04-1.27]), and 41-50 years (+1.75; 1.63 [1.34-1.98]), but not in individuals aged <21 or 51+ years.

CONCLUSIONS

Implementation of recreational cannabis policies resulted in increased simultaneous use of cannabis and alcohol, supporting the complementarity hypothesis, but only among adults aged 21+. Efforts to minimize harms related to simultaneous cannabis/alcohol use are critical, especially in states with RCLs. Future studies should investigate cultural norms, perceived harm, and motives related to simultaneous use.

Do We Have Structure, Process and Outcomes to Support Cannabis as Supportive Therapy in Cancer?

Cannabis is becoming more popular and more available in the United States. It has been approved for use by multiple states for various conditions and several states now allow recreational cannabis. We explore the structure of cannabis distribution, the process of acquisition, outcomes, and the safety of cannabis in the United States.

Recreational marijuana laws and the misuse of prescription opioids: Evidence from National Survey on Drug Use and Health microdata

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.

The Synthetic Cannabinoid WIN55,212-2 Can Disrupt the Golgi Apparatus Independent of Cannabinoid Receptor-1

The synthetic cannabinoid WIN55,212-2 (WIN) is widely used as a pharmacological tool to study the biologic activity of cannabinoid receptors. In contrast to many other cannabinoid agonists, however, WIN also causes broad effects outside of neurons, such as reducing inflammatory responses, causing cell cycle arrest, and reducing general protein expression. How exactly WIN causes these broad effects is not known. Here we show that WIN partially disrupts the Golgi apparatus at nanomolar concentrations and fully disperses the Golgi apparatus in neuronal and non-neuronal cells at micromolar concentrations. WIN55,212-3, the enantiomer of WIN; JWH-018, a related alkylindole; or 2-arachidonoylglycerol, an endocannabinoid, did not cause Golgi disruption, suggesting that the effect was specific to the chirality of WIN. WIN treatment also perturbed the microtubule network. Importantly, WIN disrupted the Golgi in primary cortical neurons derived from mice where cannabinoid receptor-1 (CB1) was genetically knocked out, indicating that the effects were independent of CB1 signaling. The Golgi dispersion could not be explained by WIN's action on peroxisome proliferator-activated receptors. Our results show that WIN can disrupt the Golgi apparatus independent of CB1 in cultured cells. These effects could contribute to the unique physiologic effects that WIN exhibits in neuronal behavior, as well as its role as an antiproliferative and anti-inflammatory agent. SIGNIFICANCE STATEMENT: The synthetic cannabinoid WIN55,212-2 (WIN), widely used to investigate the cannabinoid system, also shows unique broader effects at cellular and organismal levels compared to endogenous cannabinoids. Our study shows that WIN can disrupt the Golgi apparatus and the microtubule network in multiple cell types, independent of cannabinoid receptors. These results could explain how WIN reduces surface levels of proteins and contributes to the unique physiological effects observed with WIN.

Daily Marijuana Use Predicts HIV Seroconversion Among Black Men Who Have Sex with Men and Transgender Women in Atlanta, GA

We evaluated whether different types of substance use predicted HIV seroconversion among a cohort of 449 Black men who have sex with men (MSM) and transgender women (TGW). A community-based sample was recruited in Atlanta, GA between December 2012 and November 2014. Participants completed a survey and were tested for STIs (Chlamydia and gonorrhoeae using urine samples and rectal swabs) at baseline. HIV testing was conducted at 12-months post enrollment. Multivariable binary logistic regression was used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CI) for associations between substance use and HIV seroconversion. By 12-month follow-up, 5.3% (n = 24) of participants seroconverted. In multivariable analyses, daily marijuana use was positively associated with HIV seroconversion (aOR 3.07, 95% CI 1.11-8.48, P = 0.030). HIV incidence was high and daily marijuana use was associated with a more than threefold increased odds of HIV seroconversion among a community-based cohort of Black MSM and TGW.

Societal Costs and Outcomes of Medical and Recreational Marijuana Policies in the United States: A Systematic Review

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.

Association between fatal opioid overdose and state medical cannabis laws in US national survey data, 2000-2011

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.

Medical Cannabis Patients Report Improvements in Health Functioning and Reductions in Opiate Use

Purpose: Opioid use rates have dropped as North American patients gain access to medical cannabis, indicating a harm reduction role, yet health outcomes remain mostly unexplored. This study presents self-reported medical cannabis use, perceptions of health functioning, and changes in opioid pain medication use in Florida medical cannabis patients.Methods: Patients (n = 2,183) recruited from medical dispensaries across Florida completed a 66-item cross-sectional survey that included demographic, health, and medication usage items, along with items from the Medical Outcomes Survey (SF-36) to assess health functioning before and after cannabis initiation.Results: Most participants were between the ages of 20 and 70 years of age (95%), over 54% were female, 47% were employed, and most (85%) were white. Commonly reported ailment groups were Pain and Mental Health combined (47.92%), Mental Health (28.86%) or Pain (9.07%). Health domains of bodily pain, physical functioning, and social functioning improved while limitations due to physical and emotional problems were unchanged. Most patients rated medical cannabis as being important to their quality of life. Many (60.98%) reported using pain medications prior to medical cannabis, 93.36% of these reported a change in pain medication after medical cannabis. The majority of participants (79%) reported either cessation or reduction in pain medication use following initiation of medical cannabis and 11.47% described improved functioning.Conclusions: The findings suggest that some medical cannabis patients decreased opioid use without harming quality of life or health functioning, soon after the legalization of medical cannabis. The public health implications of medical cannabis as an alternative pain medication are discussed.

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

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.

Health Outcomes among Adults Initiating Medical Cannabis for Chronic Pain: A 3-month Prospective Study Incorporating Ecological Momentary Assessment (EMA)

In response to the need of more rigorous data on medical cannabis and chronic pain, we conducted a 3-month prospective study incorporating ecological momentary assessment (EMA) to examine the effects of medical cannabis on pain, anxiety/depression, sleep, and quality of life. Data were collected from 46 adults (Mean age=55.7±11.9, 52.2% male) newly initiating medical cannabis treatment for chronic pain. Participants completed a baseline survey, EMA for approximately 1 week pre- and up to 3 weeks post- medical cannabis treatment, and a 3-month follow-up survey. The self-reported EMA data (2535 random and 705 daily assessments) indicated significant reductions in momentary pain intensity (b = -16.5, p < .001, 16.5 points reduction on 0-100 visual analog) and anxiety (b = -0.89, p < .05), and significant increase in daily sleep duration (b = 0.34, p < .01) and sleep quality (b = 0.32, p <.001) after participants initiated medical cannabis for a few weeks. At 3 months, self-reported survey data showed significantly lower levels of worst pain (t = -2.38, p < .05), pain interference (t = -3.82, p < .05), and depression (t = -3.43, p < .01), as well as increased sleep duration (t = 3.95, p < .001), sleep quality (t = -3.04, p < .01), and quality of life (t = 4.48, p < .001) compared to baseline. In our sample of primarily middle-aged and older adults with chronic pain, medical cannabis was associated with reduced pain intensity/inference, lower anxiety/depression, and improved sleep and quality of life.

Racial and Ethnic Differences in Cannabis Use Following Legalization in US States With Medical Cannabis Laws

IMPORTANCE

Little is known about changes in cannabis use outcomes by race and ethnicity following the enactment of recreational cannabis laws (RCLs).

OBJECTIVES

To examine the association between enactment of state RCLs and changes in cannabis outcomes by race and ethnicity overall and by age groups in the US.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used restricted use file data from the National Surveys of Drug Use and Health between 2008 and 2017, which were analyzed between September 2019 and March 2020. National survey data included the entire US population older than 12 years.

MAIN OUTCOMES AND MEASURES

Self-reported past-year and past-month cannabis use and, among people that used cannabis, daily past-month cannabis use and past-year Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) cannabis use disorder. Multi-level logistic regressions were fit to estimates changes in cannabis use outcomes by race and ethnicity overall and by age between respondents in states with and without enacted RCLs, controlling for trends in states with medical cannabis laws or no cannabis laws.

RESULTS

A total of 838 600 participants were included for analysis (mean age, 43 years [range, 12-105 years]; 434 900 women [weighted percentage, 51.5%]; 511 900 participants (weighted percentage, 64.6%) identified as non-Hispanic White, 99 000 (11.9%) as non-Hispanic Black, 78 400 (15.8%) as Hispanic, and 149 200 (7.6%) as other (including either Native American, Pacific Islander, Asian, or more than 1 race or ethnicity). Compared with the period before RCL enactment, the odds of past-year cannabis use after RCL enactment increased among Hispanic (adjusted odds ratio [aOR], 1.33; 95% CI, 1.15-1.52), other (aOR, 1.31; 95% CI, 1.12-1.52), and non-Hispanic White (aOR, 1.21; 95% CI, 1.12-1.31) populations, particularly among those aged 21 years or more. Similarly, the odds of past-month cannabis use increased among Hispanic (aOR, 1.43; 95% CI, 1.22-1.69), other (aOR, 1.43; 95% CI, 1.20-1.70), and non-Hispanic White (aOR, 1.24; 95% CI, 1.13-1.35) populations after RCL enactment. No increases were found in the odds of past-year or past-month cannabis use post-RCL enactment among non-Hispanic Black individuals or among individuals aged 12 to 20 years for all race and ethnicity groups. In addition, among people who used cannabis, while no increases were found in past-month daily cannabis in any racial or ethnic group, the odds of cannabis use disorder increased post-RCL among individuals categorized as other overall (aOR, 1.45; 95% CI, 1.07-1.95), but no increases were found by age group.

CONCLUSIONS AND RELEVANCE

Changes in cannabis use by race and ethnicity that may be attributable to policy enactment and variations in recreational policy provisions should be monitored. To ensure that the enactment of recreational cannabis laws truly contributes to greater equity in outcomes and adheres to antiracist policies, monitoring unintended and intended consequences that may be attributable to recreational cannabis use and similar policies by race and ethnicity is needed.

Prevalence and correlates of non-fatal overdose among people who use drugs: findings from rapid assessments in Massachusetts, 2017-2019

BACKGROUND

People who experience non-fatal overdose (NFOD) are at high risk of subsequent overdose. With unprecedented increases in fentanyl in the US drug supply, many Massachusetts (MA) communities have seen a surge in opioid-related overdoses. The objective of this study was to determine factors associated with lifetime and past year NFOD in at-risk MA communities.

METHODS

We conducted multiple rapid assessments among people who use drugs (PWUD) in eight MA communities using non-probability sampling (purposive, chain referral, respondent-driven) methods. We collected sociodemographic, substance use, overdose history, substance use treatment, and harm reduction services utilization data. We examined the prevalence of NFOD (lifetime and past year) and identified factors associated with NFOD through multivariable logistic regression analyses in a subset of 469 study participants between 2017 and 2019.

RESULTS

The prevalence of lifetime and last year non-fatal opioid overdose was 62.5% and 36.9%, respectively. Many of the study participants reported heroin (64%) and fentanyl (45%) use during the 30 days preceding the survey. Nonprescription buprenorphine and fentanyl use were independently associated with higher odds of lifetime NFOD, while marijuana use was associated with lower odds of lifetime NFOD (p < 0.05). Injection as the route of administration, benzodiazepine, nonprescription buprenorphine, heroin, and fentanyl use were independently associated with higher odds, while methadone use was associated with lower odds of past year NFOD (p < 0.05).

CONCLUSION

We documented a high prevalence of past year and lifetime NFOD among PWUD in MA. Our findings provide indicators that can help inform interventions to prevent overdoses among PWUD, including overdose prevention, medication treatment, and naloxone distribution.

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

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.

How medical are states' medical cannabis policies?: Proposing a standardized scale

BACKGROUND

There are important differences in medical cannabis laws across the U.S.. However, prior studies investigating the effect of medical cannabis laws on outcomes disregard this heterogeneity. Findings from the body of literature using a simple dichotomous assessment of whether a particular state has enacted a medical cannabis law are equivocal or conflicting. To advance the science, a national advisory group of experts in medical cannabis developed and utilized a systematic methodology, the "medicalization of cannabis laws standardized scale" (MCLaSS), to characterize and quantify state laws' degree of medicalization, the extent to which medical cannabis is treated similarly to pharmaceutical medications.

METHODS

We conducted a systematic review of state-level medical cannabis laws in the U.S. Using the novel MCLaSS, we calculated seven domain scores (patient-clinician relationship, manufacturing and testing, product labeling, types of products, supply and dose limit, prescription drug monitoring program, and dispensing practices) and a summary score for each state which had enacted medical cannabis laws as of July 2019.

RESULTS

There is substantial heterogeneity in the degree of medicalization of states' medical cannabis laws, as demonstrated by the MCLaSS summary score, which ranged from 23 (least medicalized) to 86 (most medicalized).

CONCLUSION

This methodology will advance the evidence base about the impact of medical cannabis laws on patient and public health outcomes, which is urgently needed to ensure the development of policies that minimize the risks and maximize the benefits of medical cannabis.

The prospective association between illicit drug use and nonprescription opioid use among vulnerable adolescents

In recent years, more than half of all drug overdose deaths in United States involved an opioid. To address this epidemic, antecedents to opioid misuse must be identified and empirically validated. The objective of the current investigation was to examine whether illicit drug use was prospectively associated with nonprescription opioid use among adolescents from a vulnerable population with a greater prevalence of substance abuse. A population-based cohort study of 1060 adolescents from 29 alternative high schools in southern California was conducted over a two-year period. A total of 929 adolescents (mean age 17.5 years, 49.9% female, 76.4% Hispanic) who had not experimented with nonprescription opioids at the baseline assessment were included in the analytic sample. The outcome was self-reported use of nonprescription opioids within two years. The predictors tested were illicit drug use, illicit drug use excluding marijuana, and the use of nonmedical marijuana. Covariates included age, sex, ethnicity, socioeconomic status, parental education, weekly income, sensation seeking, stress, anxiety, depression, and the use of alcohol and nicotine products. Multilevel, covariate-adjusted logistic regression models indicated that the odds of experimentation with nonprescription opioids was greater among adolescents who had used illicit drugs or illicit drugs excluding marijuana. Nonmedical marijuana use alone was a statistically significant predictor in unadjusted but not covariate-adjusted models. While prior studies have examined the progression from nicotine, alcohol, and marijuana use to nonprescription opioid use, the present findings emphasize the importance of illicit drug use as a detectable and empirically supported risk factor for future opioid misuse.

Protocol: mixed-methods study of how implementation of US state medical cannabis laws affects treatment of chronic non-cancer pain and adverse opioid outcomes

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.

Medical Marijuana Laws, Marijuana Use, and Opioid-Related Outcomes among Women in the United States

BACKGROUND

In the context of the opioid epidemic, a limited but growing body of literature has found state medical marijuana laws (MMLs) to be associated with lower levels of opioid prescribing. However, robust evidence linking state MMLs with individual-level opioid-related outcomes is lacking, particularly among women. This finding is especially true for pregnant and parenting women, who have been disproportionately affected by the opioid crisis.

METHODS

Using data drawn from the 2002-2014 National Survey on Drug Use and Heath, the study uses a difference-in-differences estimation strategy to compare opioid-related outcomes (opioid misuse initiation, opioid misuse in the past month and past year, and opioid use disorder) among all women, pregnant women, and parenting women in states with and without MMLs (before and after implementation). The study also investigates the impact of MMLs on marijuana use and marijuana use disorder.

RESULTS

The findings indicate that MMLs were not associated with opioid misuse, opioid misuse initiation, or opioid use disorder among all women, pregnant women, and parenting women. These laws were, however, positively correlated with marijuana use and marijuana use disorder among all women and women with children. In addition, MMLs were associated with an increase in the frequency of opioid misuse for pregnant women and a decrease in the frequency of opioid misuse for parenting women.

CONCLUSIONS

This finding suggests that, although medical marijuana may be viewed by some as a substitute for opioid analgesics, MMLs may not be an effective policy tool to tackle the opioid epidemic among women, especially pregnant and parenting women.

A Rapid Review of the Impact of Systems-Level Policies and Interventions on Population-Level Outcomes Related to the Opioid Epidemic, United States and Canada, 2014-2018

OBJECTIVES

In the United States, rising rates of overdose deaths and recent outbreaks of hepatitis C virus and HIV infection are associated with injection drug use. We updated a 2014 review of systems-level opioid policy interventions by focusing on evidence published during 2014-2018 and new and expanded opioid policies.

METHODS

We searched the MEDLINE database, consistent with the 2014 review. We included articles that provided original empirical evidence on the effects of systems-level interventions on opioid use, overdose, or death; were from the United States or Canada; had a clear comparison group; and were published from January 1, 2014, through July 19, 2018. Two raters screened articles and extracted full-text data for qualitative synthesis of consistent or contradictory findings across studies. Given the rapidly evolving field, the review was supplemented with a search of additional articles through November 17, 2019, to assess consistency of more recent findings.

RESULTS

The keyword search yielded 535 studies, 66 of which met inclusion criteria. The most studied interventions were prescription drug monitoring programs (PDMPs) (59.1%), and the least studied interventions were clinical guideline changes (7.6%). The most common outcome was opioid use (77.3%). Few articles evaluated combination interventions (18.2%). Study findings included the following: PDMP effectiveness depends on policy design, with robust PDMPs needed for impact; health insurer and pharmacy benefit management strategies, pill-mill laws, pain clinic regulations, and patient/health care provider educational interventions reduced inappropriate prescribing; and marijuana laws led to a decrease in adverse opioid-related outcomes. Naloxone distribution programs were understudied, and evidence of their effectiveness was mixed. In the evidence published after our search's 4-year window, findings on opioid guidelines and education were consistent and findings for other policies differed.

CONCLUSIONS

Although robust PDMPs and marijuana laws are promising, they do not target all outcomes, and multipronged interventions are needed. Future research should address marijuana laws, harm-reduction interventions, health insurer policies, patient/health care provider education, and the effects of simultaneous interventions on opioid-related outcomes.

Medical Marijuana, Recreational Cannabis, and Cardiovascular Health: A Scientific Statement From the American Heart Association

Cannabis, or marijuana, has potential therapeutic and medicinal properties related to multiple compounds, particularly Δ-9-tetrahydrocannabinol and cannabidiol. Over the past 25 years, attitudes toward cannabis have evolved rapidly, with expanding legalization of medical and recreational use at the state level in the United States and recreational use nationally in Canada and Uruguay. As a result, the consumption of cannabis products is increasing considerably, particularly among youth. Our understanding of the safety and efficacy of cannabis has been limited by decades of worldwide illegality and continues to be limited in the United States by the ongoing classification of cannabis as a Schedule 1 controlled substance. These shifts in cannabis use require clinicians to understand conflicting laws, health implications, and therapeutic possibilities. Cannabis may have therapeutic benefits, but few are cardiovascular in nature. Conversely, many of the concerning health implications of cannabis include cardiovascular diseases, although they may be mediated by mechanisms of delivery. This statement critically reviews the use of medicinal and recreational cannabis from a clinical but also a policy and public health perspective by evaluating its safety and efficacy profile, particularly in relationship to cardiovascular health.

In our war against the opioid epidemic, could 'weed' be a winner?

INTRODUCTION

The opioid epidemic has resulted in the deaths of millions of Americans and was declared a public health emergency in 2017. In response, many states have enacted policies and analyzed various interventions for harm reduction and overdose prevention, which have embraced limited success. With more states legalizing medical marijuana, another intervention of interest in pain management, much research has since focused on the potential for medical marijuana laws (MMLs) to curb the opioid epidemic. Nonetheless, marijuana legalization and its use for medical purposes has been a polarizing debate from ethical, social, and clinical perspectives.

AREAS COVERED

We examine evidence on the merits of medical marijuana to address its potential as a diversion from prescription painkillers. Additionally, we review the impact of MMLs on opioid-related outcomes. Furthermore, we provide multi-layered recommendations for future directions in the evaluation of medical marijuana and MMLs as potential mitigators of the opioid epidemic.

EXPERT OPINION

Despite limited and mixed evidence of efficacy, medical marijuana may still play an important role in addressing the opioid epidemic in the United States. Furthermore, we believe coordinated responses among the federal government, states, researchers, and patients are crucial in producing more robust evaluations of medical marijuana and MMLs.

Medical cannabis laws and medical and non-medical prescription stimulant use among a nationally representative sample of US Adults: Examining the role of sexual identity and gender

BACKGROUND

Medical marijuana laws (MMLs) can impact marijuana and opioid use, but the relationship between MMLs and other drugs, such as prescription stimulants, remains unexamined. Because lesbian, gay and bisexual (LGB) individuals report higher levels of prescription stimulant use than heterosexuals, we explored the relationship between MMLs and past-year medical and non-medical stimulant use by sexual identity and gender.

METHODS

We pooled 2015-2017 National Survey on Drug Use and Health data for adults (n = 126 463), and used survey-weighted multinomial logistic regression to estimate odds of past-year (a) medical prescription stimulant use, (b) non-medical prescription stimulant use and (c) non-medical versus medical stimulant use. We stratified by gender, adjusted for sociodemographic characteristics, and tested the interaction between MML state residence and sexual identity.

RESULTS

Bisexual men had higher medical (6.4% versus 4.1%; aROR=1.93[1.29-2.88]) and non-medical stimulant use 6.6% versus 2.4%; aROR=2.23[1.44-3.44]) than heterosexual men. Bisexual women had higher non-medical stimulant use (6.8% versus 1.6%; aROR=1.54[1.23-2.93] than heterosexual women. Female (aROR=0.70[0.62-0.78]) and male (aROR=0.74[0.66-0.82]) heterosexuals in MML states had lower odds of medical stimulant use than in non-MML states. Bisexual men in MML states had lower odds of medical (aROR=0.36[0.21-0.61]) and non-medical stimulant use (aROR=0.48[0.29-0.81]) than bisexual men in non-MML states. Similar patterns emerged for bisexual women's non-medical use (aROR=0.57[0.40-0.81]).

CONCLUSION

Prescription stimulant use was higher in non-MML states for most LGB subgroups. MMLs may differentially impact stimulant use, primarily for bisexual men and women. States enacting MMLs should consider potential impacts on drugs other than marijuana, especially among LGB populations.

Association Between Recreational Marijuana Legalization in the United States and Changes in Marijuana Use and Cannabis Use Disorder From 2008 to 2016

IMPORTANCE

Little is known about changes in marijuana use and cannabis use disorder (CUD) after recreational marijuana legalization (RML).

OBJECTIVES

To examine the associations between RML enactment and changes in marijuana use, frequent use, and CUD in the United States from 2008 to 2016.

DESIGN, SETTING, AND PARTICIPANTS

This survey study used repeated cross-sectional survey data from the National Survey on Drug Use and Health (2008-2016) conducted in the United States among participants in the age groups of 12 to 17, 18 to 25, and 26 years or older.

INTERVENTIONS

Multilevel logistic regression models were fit to obtain estimates of before-vs-after changes in marijuana use among respondents in states enacting RML compared to changes in other states.

MAIN OUTCOMES AND MEASURES

Self-reported past-month marijuana use, past-month frequent marijuana use, past-month frequent use among past-month users, past-year CUD, and past-year CUD among past-year users.

RESULTS

The study included 505 796 respondents consisting of 51.51% females and 77.24% participants 26 years or older. Among the total, 65.43% were white, 11.90% black, 15.36% Hispanic, and 7.31% of other race/ethnicity. Among respondents aged 12 to 17 years, past-year CUD increased from 2.18% to 2.72% after RML enactment, a 25% higher increase than that for the same age group in states that did not enact RML (odds ratio [OR], 1.25; 95% CI, 1.01-1.55). Among past-year marijuana users in this age group, CUD increased from 22.80% to 27.20% (OR, 1.27; 95% CI, 1.01-1.59). Unmeasured confounders would need to be more prevalent in RML states and increase the risk of cannabis use by 1.08 to 1.11 times to explain observed results, indicating results that are sensitive to omitted variables. No associations were found among the respondents aged 18 to 25 years. Among respondents 26 years or older, past-month marijuana use after RML enactment increased from 5.65% to 7.10% (OR, 1.28; 95% CI, 1.16-1.40), past-month frequent use from 2.13% to 2.62% (OR, 1.24; 95% CI, 1.08-1.41), and past-year CUD from 0.90% to 1.23% (OR, 1.36; 95% CI, 1.08-1.71); these results were more robust to unmeasured confounding. Among marijuana users in this age group, past-month frequent marijuana use and past-year CUD did not increase after RML enactment.

CONCLUSIONS AND RELEVANCE

This study's findings suggest that although marijuana legalization advanced social justice goals, the small post-RML increase in risk for CUD among respondents aged 12 to 17 years and increased frequent use and CUD among adults 26 years or older in this study are a potential public health concern. To undertake prevention efforts, further studies are warranted to assess how these increases occur and to identify subpopulations that may be especially vulnerable.

Trends in Opioid Misuse among Marijuana Users and Non-Users in the U.S. from 2007-2017

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.