T

he take-home message from research published last week in JAMA Internal Medicine — let’s liberalize access to marijuana as a way to address the raging opioid epidemic — captured the public imagination. We disagree. Supporting medical or recreational marijuana as an alternative to opioids for conditions like chronic pain is a bad idea, especially for America’s youths.

Using state-level data, the authors of the JAMA study evaluated opioid-prescribing trends to Medicaid patients between 2011 and 2016 in states that started to implement medical and adult-use marijuana laws and compared them to rates in the remaining states. Opioid prescribing was about 6 percent lower in states with medical marijuana laws than those without.

Though the results are intriguing, the study had several limitations, which the authors point out: The cross-sectional design of the study makes it impossible to say that medical marijuana use caused the reduction in opioid prescribing. There wasn’t information to account for the strength or dosage of marijuana prescriptions, and there was no change in opioid prescribing in Connecticut and Maryland, which both have medical marijuana programs.

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Public health efforts inevitably involve trade-offs, but interventions that are broadly disseminated must have minimal harms. For example, while vaccine reactions can be serious and even lethal, they are exceedingly rare. Not so for harms associated with marijuana use. There is ample evidence that individuals — especially adolescents — who use marijuana have much higher rates of mood, anxiety, and psychotic disorders than their peers. The loss of motivation that we see in so many of our patients who use marijuana, its negative impact on functioning at school or at work, and its likely connection with cognitive decline are other serious and common harms.

Adolescents who use marijuana are also more likely to misuse prescription opioid medications. In our experience, nearly all of our patients with opioid addiction first used marijuana heavily.

Controlling access to addictive psychoactive substances is challenging. Electronic cigarettes offer an instructive example. In 2013, former Surgeon General Richard Carmona promoted electronic cigarettes as having “very meaningful harm reduction potential” for adult smokers. Unfortunately, access to electronic cigarettes was not confined to adult smokers, and today they are the bane of junior high schools around the country, even though it is illegal for children to purchase them.

Children and teens from demographic groups that had long ago rejected tobacco are now “vaping” in large numbers. Electronic cigarettes have known toxicities and other real safety risks. Teens who vape are much more likely to start smoking traditional tobacco cigarettes. As pediatric addiction medicine specialists, we have noticed large upticks in patients using electronic cigarettes, and we get calls from schools around the country asking for help in managing the problem. While some adults who smoked tobacco cigarettes may benefit from electronic cigarettes, they are addicting legions of children to nicotine. Far from being a knockout punch to tobacco, electronic cigarettes have backfired as a public health strategy.

Easing access to medical marijuana could cause the same problems.

It also risks taking attention away from the development of evidence-based treatments for individuals who have chronic medical conditions and could potentially benefit from cannabinoids, the active ingredient in marijuana.

Dispensing cannabinoids in the form of marijuana was mentioned in a 1982 Institute of Medicine report. It noted that these molecules were likely to have therapeutic value, although no pharmaceutical products were then available. The report cautioned against an “uncontrolled program” and supported the development of research infrastructure that would allow us to obtain valid scientific evidence on the effectiveness and side effects of pharmaceutical-grade cannabinoid products. Thirty-five years later, that infrastructure is still nearly entirely lacking and the science behind medical marijuana is trailing far behind marketing efforts to commercialize products for which very little evidence of effectiveness exists.

As with tobacco, many of the most serious harms from marijuana use accrue over time, making it more difficult for patients and physicians alike to identify marijuana as a cause of health problems. For example, millions of Americans have experienced episodes of intractable vomiting secondary to heavy cannabis use, and there is increasing evidence that even short exposures to secondhand marijuana smoke can harm blood vessels throughout the body, though these harms are not thoughtfully considered in marijuana policy.

Despite the problems with greater access to marijuana, a strong pro-marijuana movement has seized the opportunity to medicalize its mission and thus change public perception of the drug. The campaign has been met with tremendous success and has even altered our language, such that the word “marijuana” can now be used to refer to any product that contains cannabinoids — from the original stems and leaves of the Cannabis sativa plant to concentrated oils and cannabis-infused gummy bears and chocolate bars.

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This sloppiness has consequences. Many so-called medical marijuana studies test pharmaceutical-grade cannabinoids that bear little resemblance to the products available in marijuana dispensaries. Standardized production protocols that insure delivery of reliably formulated and evidence-based products are needed to protect patients but are practically absent for medical marijuana. Patients with chronic pain conditions deserve better from the medical profession, but current medical marijuana policies that allow medical marijuana to be sold for profit without the rigorous steps that are required for the development of all other medications serve as a disincentive to research.

Aggressive solutions to stop the opioid epidemic, one of the deadliest public health crises of our generation, are sorely needed. We don’t believe that increasing access to marijuana for controlling conditions like chronic pain is one of them. Marijuana, medical or otherwise, creates high risks for healthy people — especially young people — who make up the majority of Americans. At the same time, it is a disservice to the minority who could potentially benefit from cannabinoid therapy. We need to make sure that our solutions to the opioid crisis don’t create new and even greater problems.

Nicholas Chadi, M.D., a pediatrician who specializes in adolescent medicine at Boston Children’s Hospital, is the first pediatric addiction medicine fellow to train in North America. Sharon Levy, M.D., is the director of the Adolescent Substance Use and Addiction Program at Boston Children’s Hospital and an associate professor of pediatrics at Harvard Medical School.

  • Was referred to this article from SAM,, “Smart Approaches To Marijuana”,, So,, anything that is consided a great article from the likes of them , especially Kevin Sabet gives me a heads up on what to expect.

    Just goes to show that educated people can be ignorant, or, well paid.

  • Nicholas Chadi and Sharon Levi have ignored some seriously inconvenient facts and cherry-picked others.

    National Institute on Drug Abuse, “Is Marijuana Safe and Effective as Medicine?” February 2018, https://www.drugabuse.gov/publications/marijuana/marijuana-safe-effective-medicine

    To quote from that study:
    “Medical Marijuana Legalization and Prescription Opioid Use Outcomes”

    Begin Extract

    “NIDA funded two recent studies that explored the relationship between marijuana legalization and adverse outcomes associated with prescription opioids. The first found an association between medical marijuana legalization and a reduction in overdose deaths from opioid pain relievers, an effect that strengthened in each year following the implementation of legislation. [ref 79] The population-based nature of this study does not establish a causal relationship or give evidence for changes in pain patient behavior. [ref 80,81]

    The second NIDA-funded study, a more detailed analysis by the RAND Corporation, showed that legally protected access to medical marijuana dispensaries is associated with lower levels of opioid prescribing, lower self-report of nonmedical prescription opioid use, lower treatment admissions for prescription opioid use disorders, and reduction in prescription opioid overdose deaths. [ref 82] Notably, the reduction in deaths was present only in states with dispensaries (not just medical marijuana laws) and was greater in states with active dispensaries.”

    End extract

    Likewise, we could hardly expect the quality or scope of research to improve in the US while the DEA continues to resist de-scheduling of the drug — and this despite its proven usefulness in treating glaucoma, nausea during cancer therapy, and chronic neuropathic pain. To proclaim marijuana as a “gateway” drug for heroin is simply foolishness.

    These things being said, we should recognize that many adolescents in America are seriously at risk for habitual use or addiction to diverted medical opioids or cheaper street drugs. However, exposure to marijuana is not a “cause” of this vulnerability. Youth in economically distressed areas of the US are dropping out of their communities due to a deep hopelessness and boredom that derive from joblessness and family disruption, possibly compounded by a rise in the incidence of early prescription of stimulants in our latest medical fad, ADHD. Prescriptions of anti-depressants are also widely made to adolescents, when we know that for mild to moderate depression they have no more effectiveness than placebos. The long term effects of these medical fads are hard to predict.

    The creator of modern operations research, Norbert Weiner, informed us generations ago that “all truly interesting human behaviors are over-determined”. By that he meant that for every observed human outcome in behavior, it is possible to credibly infer multiple “causes”. Advocates such as Chadi and Levy ignore this principle to the peril of their credibility.

  • this article is a joke. first of all, the “pharmacutical grade” marijuana used in these studies is substandard, controlled by the government, tested at a thc level just above hemp. failure to gleen medicinal evidence from this “pharmaceutical grade” government tampered with weed is illogical. medicinal studies exist before this government “tampered with” weed in monographs 1 and 14 released by the National institute of drug abuse, admitting the same medicinal properties–to treat epilepsy, asthma, pain, etc–as we are “just discovering” today. these monographs were released in 1976, and 1977. the federal prohibition the writer of this article wants to continue has prevented investigation into using Cannabis to treat these conditions.

    also, alcohol kills 20,000–30,000 each year via overdose. it is wrong to crimilize people over a substance that kills no one.

    this “bottom line” nullifies any arguments used above to continue this prohibition.

    And, alcohol causes more vomiting than cannabis

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