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.
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.
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.