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.

  • Today, opiates like hydrocodone, oxycodone, and morphine flood the streets, driving up addiction rates and fatal opiate overdoses.

    The Centers for Disease Control and Prevention has officially labeled the problem an “opiate epidemic.” As experts scramble to come up with a plan that combats the nation’s dependence on opiates, a new study published last week in the journal JAMA Internal Medicine indicates medical marijuana might be the key.

    Over the past two decades, deaths from drug overdoses have become the leading cause of injury death in the United States. In 2011, 55 percent of drug overdose deaths were related to prescription medications; 75 percent of those deaths involved opiate painkillers. However, researchers found that opiate-related deaths decreased by approximately 33 percent in 13 states in the following six years after medical marijuana was legalized.

    https://drugabuse.com/legalizing-marijuana-decreases-fatal-opiate-overdoses/

  • ..so inanimate objects like guns don’t kill people but inanimate objects like hemp plants kill people? You can’t have it both ways

  • You have that right! Also the Maryland MMJ has only been dispensing MMJ for less then six months, no data or very little.

  • ” .. You can do anything you want – absolutely anything for the rest of your life – as long as you are willing to pay the price ..”

    We’re not paying for your dope problems — got it? Good.

    • ” According to The Economic Impact of Illicit Drug Use on American Society, last published by the Department of Justice in 2011, enforcing illegal drug laws imposes an annual cost on the American criminal justice system of $56 billion; while incarceration of drug offenders imposes an annual cost of $48 billion.

      That’s $104 billion spent annually by states and cities on two aspects of the drug war (and doesn’t include treatment, public assistance, and a slew of other costs), compared to roughly $21 billion spent by the federal government. 

  • Let the accusations begin! Now the potheads will cuss, insult, and be outraged that anyone could say anything negative about their beloved marijuana. We may not be able to agree on much, but one thing you can be sure of: Marijuana smokers are consistent.

    Taking a page from Big Tobacco’s book, Big Marijuana has a similar tactic. Make false accusations about every legitimate study that comes out showing marijuana is bad for your health and mental health. Mustn’t say that! After all, Leafly says marijuana is good for what ails ya and that just has to be the final word on the bad effects of marijuana use.

    Denial is one of the main component of any addiction to a mind altering substance. Addicts skip from one substance to the next, conning, excusing, denying and continuing to alter their brains. The two main gateway substances are alcohol and marijuana.

    I’ve been in recovery for over 30 years, and my main substance of choice was marijuana when I got sober. Marijuana had turned on me and no longer made me feel relaxed and happy, instead giving me a terrible headache and making me feel like I no longer wanted to live. I quit all mind altering substances on the day I got sober from my marijuana addiction.

    I’ve been sitting in meetings all these years, working with others, staying sober, and working on my self. The sad trend I see among younger people these days is that they have been raised by pot smoking parents who have taught their kids that marijuana is wonderful and much less of a health issue than smoking a cigarette. So the people under 45 believe that marijuana is this wonder substance – sort of a like an aspirin – and not a mind altering substance. They are out at a picnic or at work or wherever, having started to recover from meth or heroin or alcohol, when their buddy, friend or relative offers to smoke a joint with them.

    They accept the offer because they don’t even realize marijuana is a mind altering substance – they have no clue. They have had so much smoke blown up their behinds about marijuana that they go back out without even realizing it!

    To the pot smokers who are going to scream, cuss me out, and accuse me of being a liar, I know better. You can’t kid a kidder. The United Nations conducted a study of world drug addiction a few years ago and found that the US has 5% of the world’s population, but 80% of the world’s addicts. And you want to add to that? You want to be a part of the problem, rather than part of the solution? That is on you. As for me, I want my daughter, SIL and granddaughter to live and grow up knowing that there is no answer to be found by using mind altering substances, so my husband and I are staying sober and being an example to them and many others.

    You can do anything you want – absolutely anything for the rest of your life – as long as you are willing to pay the price. Because there is a price tag attached to everything you do, everything you say, and the way you think. Maturity is looking at that price tag before you take the action. Today our society has a plethora of problems as the result of the actions pot smokers are taking and the rest of us are having to pay the price. One of the prices our society is paying is that our kids now think that it is hunky dory to smoke, drink and do drugs – and that is resting on the shoulders of the people who set that example for them and on those who are making a great deal of money selling a product that is harmful in too many ways to detail here.

  • “This sloppiness has consequences.” Yeah, so does the sloppiness of this article. Interesting how the authors start out questioning the JAMA article and discussing lack of clear causation, methodological constraints, etc, and then goes on to give random anecdotal accounts that intentionally imply causation (“nearly all of our patients with opioid addiction first used marijuana heavily”) without any statistical validation whatsoever. So much of this is just fear mongering.

    Also I find the idea that we should withhold potential treatments for people who are suffering because this might theoretically create risk for other people (even if those people “make up the majority of Americans”) ethically problematic.

    Finally, I agree teens should not be smoking marijuana but such behavior is definitely not “an even greater problem” than the opioid epidemic. Give me a break.

    • ” .. such behavior is definitely not “an even greater problem” than the opioid epidemic ..”

      Two wrongs make a right? How obtuse.

      This is going to cost taxpayers $100000000s. Great.

    • Urko-

      No. Prohibition costs taxpayers FAR more than legalizing/regulating cannabis.

      Antiquated notions like yours are a problem that we, as The People of this Nation, are collectively solving.

      Big Prohibition uses fear-tactics to perpetuate their lies for profit.

      Educate yourself.

  • The title of this article “Easing access to marijuana is not a way to solve the opioid epidemic” removes any credibility from whatever comes after. No one has ever proposed that it would solve the opioid epidemic. Possibly it will keep some individuals from becoming addicted; data point in that direction but aren’t totally convincing. When you start with such a ridiculous opening it means that whatever comes next won’t be a reasoned argument. Which is indeed the case. It’s too bad that people set up ridiculous hypotheses to argue against, as balanced discussions would be helpful.

    • Reality: many docs will NOT ‘script medical MJ .. because it is UNKNOWN whether MJ will *negatively* interact with existing meds.

      IMHO, medical MJ is going to cost taxpayers $100000000s .. as usual ..

    • Urko-

      You are rattling off Project SAM talking points, that are absolutely false.

      Are you affiliated with SAM? And did you know that board members of SAM have taken money from PURDUE PHARMACY? It’s true. Look it up.

    • Wow, great, so many reality-haters here. No wonder the taxpayer debt is $21.1 TRILLION.

      Thanks, STAT!

    • “No wonder the taxpayer debt is $21.1 TRILLION.”

      …and your buddy trump just signed a $1.3 democrat-approved spending bill with half a billion for planned parenthood. Spare me your whining about the debt

  • Let’s see what happens. Massachusetts joined this wagon a tad on the late side. More progressive west coast states have been there done that. All appears well out west and Vanvover. Chadi/Levy are probably a tad on the conservative side of what the research is telling us. IMO they’re wong. They should be progressive enough to understand trying new approaches can pay off on occasion. This is such an occassion.

  • These are tired arguments. Legalization doesn’t make marijuana available to adolescents. But they already have easy accesses to it illegally. Making a substance legal trends to dry up any illegal markets, as is true with alcohol. Legalization would largely destroy the illegal black market sources, making it harder for adolescents to obtain — especially considering that it’s now incredibly easy for them to get.

    • Fatal flaws:

      — There are already reports that due to the big regulations on medMJ — illegal markets still exist. Medical MJ is expensive. Like in NYC and cigarette taxes.

      — Alcohol and MJ are 100% different. A 12-year-old can grow MJ, in a planter. S/he will find brewing booze, a lot more complicated.

    • Urko, sounds like you don’t know what “fatal” means. And I agree that anyone could grow their own plant — since marijuana has grown naturally all over the world for millenia, stamping out individual plants would be like trying to eliminate homegrown tomatoes. Good luck eliminating all the individual plants here and there, whatever its legal status. But legalization would help eliminate the criminal black market, which is an enormous benefit, particularly because of the violence inherent in it.

  • “In our experience, nearly all of our patients with opioid addiction first used marijuana heavily.”

    Observer bias — they spend their days with opioid-addicted patients, not the people who use marijuana and not opioids, of which there are many.

    I absolutely agree that adolescents, with all of the critical brain development that happens at that age, should not be using marijuana. I will be having a lot of frank talks with my kids as they approach that age and inevitably their peers start offering it to them.

    Dose for dose, alcohol is much worse for people than marijuana, but outlawing alcohol sure didn’t work. I’m glad people are coming to their senses around cannabis.

    • The costs of alcoholism would 50% pay for an ACA. In Britain, the highly-stressed NHS flat-out told NYE boozers “NHS does NOT stand for ‘National Hangover Service.”

      Doesn’t make sense to me, madam.

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