The 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.
I work with students and they all believe marijuana/cannabis is safe. Safer does not mean safe. The tobacco industry worked hard to get its share of the youth market because it resulted in lifelong customers and $$. It is naive to think that the marijuana/cannabis industry as part of cooperate America is not going to be greedy and stay away from targeting young users. Also, I always hesitate to comment on any of these forums because so many people don’t seem to be interested in thoughtful dialogue anymore…which is pretty sad
Smoking MJ is no different than smoking tobacco. To think otherwise is flat-out ignorant, absurd, and ridiculous.
Urko, what’s the typical nicotine content of marijuana?
This is a good example of people with a degree yapping about a subject they have no real knowledge about.
“Kris” you are definitely a woman in her 60’s. I have narrowed down the main opponents of legalization into two main groups:
1. Baby boomer women who actually believe marijuana is a gateway drug and started the opiod crisis. These women also usually swoon for anything related to the Kennedy’s (“That Bobby Jr. is so handsome”)
2. Middle-aged men, usually white and overweight, who live for alcohol!!
Very scientific I know;)
They always focus on children because there is nothing else! The other one they use now is the dangers for pregnant women. All I know is that I traded in alcohol for cannabis and my only “consequence” is no more headaches on the weekends:)
1. “Cannabis Sativa” is a type of cannabis plant. There is also cannabis indica. The differences are mainly due to the region where they are native. The plants also vary in size, effects, etc. I would think medical doctors would know this if they are so against.
2. The “what about the children” argument is a joke and very LAZY. Kids can get cannabis whenever they want now. TAXING and strictly REGULATING a product does not make it more accessible to kids.
3. My wife and I are regular cannabis users. We have masters degrees, great jobs, work out six days aweek, and raise two beautiful daughters. We used to have a drink or two to unwind. The only differences between now and then are I lost 20lbs and I no longer get headaches on the weekend if I had one too many. I think doctors such as yourselves can not even conceive of such people existing….WE DO!!!!
4. The real scourges of society are PROCESSED FOODS and ALCOHOL.
5. Cannabis is not always SMOKED. You can cook with it, use tinctures, or a vape pen(I should have left that last one out….you guys clearly love those).
6. The gateway theory……really??? Is this Nancy Reagan talking in the 1980’s?
I think that is all for know, but realize that even though you are doctors, you have ZERO credibility on this issue. I surmise you have never used cannabis or know anyone who has, because you talk about it like it is the DEVIL!!!!
Are we still having this debate? The decision has been made. It’s time to start collecting data and see the impacts of legalized marijuana. Stop with the scare tactics. If anything, misinformation and out right lying to kids is a bigger reason some kids move on from weed to opioids, because when kids realize they’ve been lied to about weed they thing they are being lied to about opioids and every other drug.
That is exactly right. Government contradiction helps fuel the opioid crisis. “The government lied about weed, they are probably lying about heroin too, it’s not addictive! They say pot will kill you and it doesn’t so heroin is more than likely harmless.” Something like that. The government itself is unwittingly contributing to the opioid crisis because they are too stubborn or stupid to change. That’s why all these so called “educated” doctors are so uninformed. IGNORANCE!!!
Not going to pay for any problems with negative drug interactions — you pay them.
I’m just curious what the so called “risks” associated with cannabis other than potentially being shot by an overzealous cop?
The big risk is that it will eat into the profits of drug companies and alcohol distributors.
…You do realize that, with legalized and regulated marijuana not unlike alcohol, youngsters would likely have a much harder time getting their hands on cannabis-based products when people are checking ID’s behind the counter? Why are you concentrating solely on adolescent use? Who is this bogeyman you guys have made up, implying they’re basically saying that “yes, marijuana would be perfect for adolescents with pain issues, let’s make sure our teens just roll a giant blunt and go to town”? Literally no one is saying to ease marijuana usage for everyone across the board, people arguing for legalization of recreational marijuana say to regulate it not unlike alcohol. You don’t even have a single sentence talking about the uses of CBD, of which there have been dozens of studies that have evidence that it can treat epilepsy, anxiety, heart disease, cancer, it goes on and on and on, all without getting you “high” but I guess those little facts would have been inconvenient to your worldview, eh?
You should be straight up embarrassed to use “think of the children” excuses against easing marijuana laws, especially as doctors. It’s 2018, you’re on the wrong side of history. I’m sure with the proper time and counseling you’ll come to terms with this hard truth.
(Also, just curious – how much have you guys accepted in donations from big pharma?)
Another difference between vaping and cannabis use is cannabis is already everywhere so there is no novelty with it like there is with vaping. Vaping is a trend that will come and go. Cannabis has been there and will always be there. The black market supplies states with no legal system if you live in a state where it’s still illegal, Your kidding yourself if you think kids can’t get thier hands on weed easier than in states with a regulated system. I guarantee if cannabis was legalized nationwide, consumption amongst teens would drop dramatically. DRUG DEALERS DONT ASK FOR ID! And they carry or have access harder drugs than cannabis making it much easier for kids to get their hands on so spare me this worn out argument that once legalization gets implemented, teen use goes up. Early studies out of Colorado backs this up.
Thank you… your comment was entirely evidence based, as opposed to the article.
First off, children have easier access to cannabis in states where it’s ILLEGAL because drug dealers don’t ask for ID unlike a legal, licensed dispensary, therefore Kids access it easier. Second, you say millions are affected by a mysterious illness caused by cannabis? This syndrome is extremely rare and only occurs in heavy cannabis consumers, not first time users so stop being dramatic. Third and most importantly, NOBODY IN THE HISTORY OF HUMAN CIVILIZATION HAS EVER DIED FROM A CANNABIS OVERDOSE!! Unlike opiates. If they work for people and is a thousand times less dangerous, then why not let people use it? Keep lobbying for the opioid companies that kill thousands of Americans every year! Wake up idiot!! So called “doctors” like you are what’s wrong with the system!!
I’m so sick of people invoking “America’s Youth” while keeping cannabis illegal! America’s youth face a far greater threat in a militarized police force trying to keep a harmless plant from them, especially kids of color. Cannabis has NEVER killled anyone, your local Sherriff on the other hand has. Which is really the bigger threat. A kid smoking some pot? Or an armed cop with an agenda? Does it really take a brain surgeon to figure that out! Wake up people!!!