Since Colorado legalized recreational marijuana, the amount of opioid prescriptions for pain fell significantly compared to two states where access to cannabis for adult-use is still illegal, a new study finds.
While a robust body of research has demonstrated a link between legal access to medical marijuana and lower use of opioids, less is known about how broader adult-use laws affect the prescribing rates of pharmaceuticals used for pain management. Researchers at the Geisinger Commonwealth School of Medicine and the University of New England were interested in addressing this gap in the literature.
For their analysis, they chose to compare Colorado with Maryland and Utah based on the fact that those two states are similar to the first-to-legalize jurisdiction in different ways: While Maryland has similar demographics in terms of population size, home ownership, education level and uninsured rates, Utah was the most geographically similar state with comparable Body Mass Index and median household income.
According to the study’s findings, which were pre-published on bioRxiv earlier this month and have yet to be peer-reviewed: “Colorado had a larger decrease in opioid distribution after 2012 than Utah or Maryland. Therefore, marijuana could be considered as an alternative treatment for chronic pain and reducing use of opioids.”
“There has been a significant decrease in the prescription opioid distribution after the legalization of marijuana in Colorado.”
Using data from a federal program managed by the Drug Enforcement Administration to keep an eye on the distribution of certain narcotics, the study’s authors looked at the prescription rates from 2007 to 2017 for nine opioid pain medications (oxycodone, fentanyl, morphine, hydrocodone, hydromorphone, oxymorphone, tapentadol, codeine, and meperidine) and two medications used to treat opioid use disorder (methadone and buprenorphine) in the three states. For a baseline comparison, they converted the amount of each drug distributed into what the equivalent would be in a dose of oral morphine in milligrams (MME).
According to the study’s analysis, Maryland had the highest amount of total pharmaceuticals distributed during the study period: In 2011, the weight of all 11 opioids peaked at 12,167 kg MME. That amount was more than twice the weight determined in Colorado and Utah, which peaked at 5,029 kg MME in 2012 and 3,429 kg in 2015, respectively. The two narcotics distributed the most in all three states were oxycodone and methadone.
When researchers looked specifically at medications prescribed to help people who misuse opioids—that is, methadone and buprenorphine—they found Utah had cut back by 31 percent over the study period. Colorado and Maryland both increased these prescriptions by 19 percent and 67 percent, respectively.
For pain medications specifically, Utah had lower rates in every year and in every drug compared to Colorado. However, its prescription rate increased by almost 10 percent over time. Meanwhile, Colorado’s prescribing rates decreased by approximately 12 percent during the decade studied, while Maryland saw a decrease of 6 percent.
“This finding was particularly notable for opioids indicated predominantly for analgesia such as hydrocodone, morphine and fentanyl.”
“Colorado and Maryland experienced an overall decrease in opioid distribution, but Colorado’s decrease was larger,” the study states. “While the nation as a whole was experiencing a decrease in opioid distribution, it was promising that Colorado’s greater decrease gives consideration to the potential impact of recreational marijuana.”
It’s unclear why Colorado saw such a significant drop in prescriptions for pain medication, but it’s hard to ignore the fact that Colorado legalized marijuana for adult use in 2012. Recent research also shows that many customers purchase marijuana from recreational dispensaries for the same reasons medical cannabis patients do: to help with pain and sleep.
There may be other variables at play, however, including guidelines issued by the Centers for Disease Control and Prevention in 2016 to address prescribing narcotics for chronic pain, the study states. Additionally, Maryland lawmakers passed a medical cannabis law in 2013, while Utah voters didn’t approve medical access until 2018.
Importantly, the authors say that lawmakers “have the duty” to consider other options to address the opioid crisis, including “marijuana as a treatment option for chronic pain.”
“If there is an initial reduction in opioid distributions in states with recreational marijuana laws, it is conceivable that opioid misuse, addiction, and overdose deaths could also fall,” they conclude. “Therefore, it may be time to reconsider the practice of automatically discharging patients from pain treatment centers for positive marijuana screens, considering this use might actually reduce their overall opioid use.”
Feds Funding Research On How Marijuana Consumers Are Impacted By Coronavirus
A top federal agency is asking researchers to submit grant applications to study how people who consume drugs—particularly those who smoke or vape marijuana or tobacco—are uniquely impacted by a coronavirus infection.
In a notice from the National Institute on Drug Abuse (NIDA) that was published last month, the agency said the rapid spread of the pandemic makes it imperative that researchers identify potential medical complications for people who contract the virus and use substances that could compromise their respiratory system or other health functions.
Two grants have been made available to scientists who are able to investigate these issues.
“As people across the U.S. and the rest of the world prepare for what could be a pandemic of the 2019 novel coronavirus, or COVID-19, the research community should be alert to the possibility that it could affect some populations with substance use disorders or HIV particularly hard,” NIDA said. “Because it attacks the lungs, COVID-19 could be an especially serious threat to those with histories of smoking tobacco or marijuana or of vaping.”
“People who use opioids or methamphetamine may also be vulnerable due to those drugs’ effects on respiratory and pulmonary health and potential effects on immune mechanisms. Likewise, those with HIV may be affected if their immune function is compromised,” the notice continues. “Additional social and environmental factors associated with drug use may worsen the transmission and treatment of COVID-19, especially among individuals who experience homelessness or incarceration, which is more common among those with a substance use disorder.”
NIDA listed a series of research objectives it hopes to expedite, including whether substance use, “especially smoking tobacco or marijuana, vaping, opioids and other drug use,” could be a risk factor in the onset or progression of the coronavirus.
It also wants to generally “understand the respiratory effects” of such behaviors, “in particular those with nicotine, marijuana, opioid, and methamphetamine use disorders.”
The notice also states that the agency is interested in learning about the impact of a coronavirus infection among pain patients who use opioids and those with opioid misuse disorders. NIDA said studies investigating how the virus “influences the outcomes for naloxone interventions for overdose reversal” are also of interest.
The agency will be accepting applications for the grants on a rolling basis through March 31, 2021.
Federal agencies have made a series of requests for scientific submissions on cannabis-related topics in recent months. For example, the Agency for Healthcare Research and Quality put out a call for studies on the impact of marijuana on pain and migraines in January.
Youth Marijuana Treatment Admissions Fell After Legalization, Study Finds
Does legalizing marijuana for adults lead to a tidal wave of teens going to treatment? Not according to a new study out of Temple University, where researchers in fact found decreases in youth admission rates for problem cannabis use in two legal states.
The findings, published this month in the journal Drug and Alcohol Dependence, run counter to speculation from legalization opponents, law enforcement and some public health experts, who have warned that relaxing cannabis laws could lead to an explosion in cannabis use disorders among children. If that’s happening, the study found, treatment admissions data so far show no sign of it.
Examining data from publicly funded substance use treatment facilities, researchers from Temple’s geography and urban studies department, found that youth treatment admissions rates for cannabis use disorder fell sharply between 2008 and 2017, nationally as well as in Colorado and Washington State, which both passed legalization laws in 2012.
“Our results indicate that [recreational marijuana legalization] in Colorado and Washington was not associated with an increase in treatment admissions,” the study concluded. “Rather, we observe a substantial decline in admissions rates across US states, with evidence suggesting a greater decline in Colorado/Washington following RML as compared to non-RML states, though this difference was not significant.”
Co-author Jeremy Mennis, a Temple professor, told Marijuana Moment that the “national decline is pretty dramatic,” noting that on average, youth admissions rates for marijuana fell by nearly half.
“It declined more in Colorado and Washington, but the difference between them and other states was not statistically significant,” he said.
In other words, at least so far, legalization doesn’t seem to have made a particularly big impact on youth admissions rates one way or the other.
“Adolescent treatment admissions for marijuana use did not increase in Colorado and Washington following [recreational marijuana legalization].”
“The admissions rate is initially higher in Colorado/Washington at the beginning of the study period,” Mennis and co-author Gerald Stahler wrote, “but declines more rapidly following [legalization] as compared to the other states.”
As the study notes, if legalizing cannabis for adults were to increase the prevalence of cannabis use disorder among youth, “one potential consequence would be an increased need for treatment.” But that increased need hasn’t been reflected in actual admissions rates.
Still, the researchers are quick to caution that a drop in treatment admissions doesn’t necessarily mean a decrease in problem marijuana use.
“We’re not sure whether cannabis use disorder is declining or just treatment admissions are declining” for some other reason, Mennis said.
Youth cannabis consumption in the U.S. “has not substantially increased over the last 10 years,” he said, but it’s not drastically fallen, either. Yet since about 2011, treatment admissions have steadily declined.
Why the drop in admissions rates? “I don’t know why,” Mennis acknowledged. “This is speculative on my part.”
One possibility is that changing attitudes toward the potential dangers of marijuana have shifted in recent years, making individuals and their loved ones less likely to seek treatment.
“The perception that using marijuana is harmful has declined across the U.S. among youth and adults,” Mennis said, “and this may affect how people view whether their marijuana use is problematic or requires treatment.”
If fewer parents see cannabis as a harmful drug, for example, “they’re probably a lot less likely to see the use of marijuana among their kids as warranting treatment,” he said. “That’s a possibility.”
Reduced stigma around cannabis generally could also be playing a role, he said, with parents perhaps less likely to refer their kids to treatment for simply experimenting with the drug absent other problems connected to such use.
Perhaps the worst-case scenario, the paper says, is that the need for treatment still exists but somehow isn’t being met:
“If [cannabis use disorder] remained stable following [recreational marijuana legalization], or increased, as recent research indicates, the dramatic decline in adolescent treatment admissions we observe in states enacting [recreational marijuana legalization] would suggest an increase in unmet need for treatment, i.e. it may be the case that admissions rates are falling because an increasing proportion of adolescents with CUD are not entering treatment.”
“Cannabis use disorder is a thing, and I think a lot of people are resistant to the idea that it can be a thing. The question is whether cannabis use disorder is actually decreasing,” Mennis said. “If cannabis use is staying the same, then there’s a bigger and bigger gap.”
Studies on cannabis use disorder have arrived at mixed conclusions about whether it’s becoming more or less common as legalization spreads to more states. A study published last year found that, contrary to the expectations of some health experts, the prevalence of cannabis use disorder among frequent cannabis users has actually decreased in recent decades.
Cannabis use disorder “decreased significantly across all ages reporting daily/almost daily cannabis use between 2002-2016,” that study found. “Cannabis dependence prevalence decreased for adolescents and young adults and was stable only among adults ages 26+ reporting daily/almost daily cannabis use.”
Photo courtesy of Martin Alonso
Federal Agency Wants Help Developing A Standard THC Dose For Marijuana Products
A top federal health agency is requesting input on a proposal to establish a standardized dose of THC in marijuana products to ensure consistency among studies into the potential therapeutic benefits and risks of cannabis.
In a notice published by the National Institute on Drug Abuse (NIDA) on Monday, the agency said that little is known about the impact of varying THC potency, and creating a standard unit could help resolve that issue. That said, the notice acknowledges that marijuana contains other compounds that could complicate any standardization, in addition to problems arising from differing methods of consumption.
Even so, “such a unit is critical for conducting rigorous cannabis research,” NIDA said.
“Recognizing that a perfect measure may not be attainable at the current time, NIDA still believes that a standard dose would improve measures of outcomes in relation to exposure; and thus, could inform policy and public health strategies around cannabis use,” the notice states, adding that the agency is looking into a five milligram THC dose as the standardized unit.
Request for Information (RFI): Inviting Comments on the Establishment and Implementation of a Standard Unit Dose of Delta-9-tetrahydrocannabinol (THC) for Cannabis Research https://t.co/RkSzihPpbP
— NIH Funding (@NIHFunding) March 23, 2020
NIDA Director Nora Volkow discussed the importance of establishing such a unit in commentary published in the journal Addiction last month.
Citing research that calls for a five milligram THC standard, Volkow said she agreed with the study’s conclusion despite complicating factors. Those factors include potential issues related to the effect of having cannabis products with the same THC level but different concentrations of other cannabinoids such as CBD.
Also, varying routes of administration could present problems in ensuring research consistency. It’s unclear how the effects of a five milligram THC unit would differ between marijuana products consumed via smoking, vaping, edibles or topicals.
The notice also calls for information about labeling requirements for cannabis products. But while that might aid in observational or epidemiological studies, a federal standard for labels wouldn’t be achievable as long as marijuana remains a prohibited substance. The Trump administration’s secretary of health and human services talked about this problem as it applies to warning labels last year.
The complexities in research beyond having a standardized measure of THC “hardly negate the value” of setting one, Volkow said in her commentary. “In fact, having and using such a standard is a prerequisite for comparing the effects of various cannabis products on THC bioavailability, pharmacokinetics and pharmacological effects, which is knowledge fundamental to studies pertaining to medical use of cannabis.”
“Although cannabis remains an illicit substance in the United States, the expanded legalization by states requires us to develop the knowledge base that can help states develop policies to minimize risk from cannabis exposures, such as limits on the THC content of cannabis products,” she said.
Due to the lack of standardization, she said that studies often show conflicting results when it comes to questions about how cannabis impacts brain development and mental health conditions, for example. There’s also a lack of consistency in research comparing the effects of high THC and low THC marijuana.
In the study Volkow references, the authors said they examined “experimental and ecological data, public health considerations and existing policy” to determine that five milligrams of THC should be the standard unit.
The director said in her commentary that in spite of the “multiple caveats and complexities, the use of a standard unit dose of THC in research is an important step for improving our ability to understand the effects of cannabis in the population.”
NIDA’s notice calls for e-mailed submissions from “the scientific research community and any other interested parties” by May 1.
Volkow has been vocal about the importance of streamlining and improving research into cannabis, and she’s laid partial blame for the the lack of studies on marijuana’s restrictive federal classification.
While it remains to be seen when that fundamental impediment will be resolved, the Drug Enforcement Administration did announce last week that it is proposing a rule that would enable it to expand the number of authorized cannabis manufacturers for research purposes.
Photo courtesy of Martin Alonso.