Could Lower Opioid Prescribing Be Due to Legalization of Medical Marijuana?

Could Lower Opioid Prescribing Be Due to Legalization of Medical Marijuana?

A pair of studies published in JAMA Internal Medicine suggest that recent reductions in opioid prescribing could be the result of the recent medical marijuana laws enacted in eight states and adult-use (recreational) marijuana in four other states, says an article in Pain Medicine News (PMN).

One study looked at the association between Medicare Part D opioid prescribing before and after medical cannabis laws (MCLs) were enacted, for the years 2010 to 2015.

The other study looked at the association between opioid prescribing for Medicaid enrollees in states legalizing both medical and adult-use marijuana from 2011 to 2016.

The first study found reductions in opioid prescribing, but some difference in rates of reduction depending on the type of state medical use regulations - retail dispensary or home cultivation.

"When dispensaries opened, we found a 14.4% reduction in opioid prescribing," said study author David Bradford, PhD, a professor of public policy at the University of Georgia. "But when MCLs [medical cannabis laws] were limited to home cultivation, there was only a 6.9% reduction in opioid prescribing. Statistically speaking, those effects were most powerfully seen for hydrocodone and morphine."
The second study found a 5.9% lower rate of opioid prescribing after state implementation of medical marijuana laws, and a 6.4% lower rate of opioid prescribing after the implementation of adult-use marijuana.

What does it all mean?

The rationale suggested by the study authors to support their cause-effect theory is that (an unknown number of) chronic pain patients may have moved from relying on opioids for pain relief to medically using marijuana instead. This, they suggest, explains the modest reductions seen in opioid prescribing.

Regardless of whether or not one agrees with the legalization of medical marijuana or recreational marijuana, or with its use as a modest pain reliever, the evidence presented in the studies is simply this:

During the years studied, marijuana was legalized in 12 states. Roughly time-coincident with this, opioid prescription rates fell modestly in some, but not all, of those states.

In other words, two things happened, and they could be connected.

What it doesn't mean

What the results of the studies don't mean, and clearly don't even suggest, is that marijuana offers some kind of solution to the opioid crisis. No one except perhaps the wildest proponents of legalizing marijuana would even think of making such a suggestion.

Not only that, the suggested cause-effect relationship between medical marijuana and reduced opioid prescribing isn't a certainty. The study years roughly parallel the period during which government agencies, from the White House and CDC on down, ran campaigns urging physicians to adopt safer opioid prescribing habits. The CDC issued new opioid prescribing guidelines, several agencies recommended more alternative, nonopioid therapies, and insurance companies were urged to cover more alternative treatments.

Those campaigns have been effective. Doctors are writing fewer and smaller opioid prescriptions - just ask any chronic pain patient how difficult it is to get an opioid prescription renewed these days.

Jeff Gudin, MD, the director of pain management and palliative care at Englewood Hospital and Medical Center, in Englewood, N.J., and a Pain Medicine News editorial advisory board member, told PMN that,

"we are in a climate of progressively declining opioid prescribing, due to the prescription drug crisis and illicit drug crisis. This has occurred simultaneously with liberalization of marijuana laws. Therefore, clinicians should be careful when determining cause and effect, as the decline in opioid prescribing may be a consequence of clinician education about safe use of opioids and completely unrelated to medical marijuana laws."

Tracy Klein, PhD, an assistant professor of nursing at Washington State University, added that the studies don't show if opioid prescribing reductions were due to,

"increased access and insurance coverage for other modalities being used more often for chronic pain, such as acupuncture or physical therapy."

The bottom line

Gudin also cautioned that prescribers should,

"recognize that the majority of opioid-related deaths are due to synthetic and illegal/illicit opioids, such as fentanyl and heroin."

Prescription opioids are heavily abused but far behind illicit opioids as the cause of death in today's opioid crisis. As for suggestions that marijuana is some kind solution to chronic pain, Gudin told PMN that it has too many problems of its own.

"Certainly we cannot conclude that more widespread use of marijuana-like substances will be the answer to the world's pain problem," he said. "Multiple reviews have shown that cannabinoids are only weak analgesics, and should play [only] an adjuvant role in multimodal analgesic therapies. It is also important to remember that marijuana use is associated with its own detrimental pathologies that we cannot overlook.”

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