Medical Cannabis Laws and Opioid Analgesic Overdose Mortality in the United States, 1999-2010
TL;DR: Examination of the association between medical cannabis laws and opioid analgesic overdose mortality in each year after implementation of the law showed that such laws were associated with a lower rate of overdose mortality that generally strengthened over time.
Abstract: Importance Opioid analgesic overdose mortality continues to rise in the United States, driven by increases in prescribing for chronic pain. Because chronic pain is a major indication for medical cannabis, laws that establish access to medical cannabis may change overdose mortality related to opioid analgesics in states that have enacted them. Objective To determine the association between the presence of state medical cannabis laws and opioid analgesic overdose mortality. Design, Setting, and Participants A time-series analysis was conducted of medical cannabis laws and state-level death certificate data in the United States from 1999 to 2010; all 50 states were included. Exposures Presence of a law establishing a medical cannabis program in the state. Main Outcomes and Measures Age-adjusted opioid analgesic overdose death rate per 100 000 population in each state. Regression models were developed including state and year fixed effects, the presence of 3 different policies regarding opioid analgesics, and the state-specific unemployment rate. Results Three states (California, Oregon, and Washington) had medical cannabis laws effective prior to 1999. Ten states (Alaska, Colorado, Hawaii, Maine, Michigan, Montana, Nevada, New Mexico, Rhode Island, and Vermont) enacted medical cannabis laws between 1999 and 2010. States with medical cannabis laws had a 24.8% lower mean annual opioid overdose mortality rate (95% CI, −37.5% to −9.5%; P = .003) compared with states without medical cannabis laws. Examination of the association between medical cannabis laws and opioid analgesic overdose mortality in each year after implementation of the law showed that such laws were associated with a lower rate of overdose mortality that generally strengthened over time: year 1 (−19.9%; 95% CI, −30.6% to −7.7%; P = .002), year 2 (−25.2%; 95% CI, −40.6% to −5.9%; P = .01), year 3 (−23.6%; 95% CI, −41.1% to −1.0%; P = .04), year 4 (−20.2%; 95% CI, −33.6% to −4.0%; P = .02), year 5 (−33.7%; 95% CI, −50.9% to −10.4%; P = .008), and year 6 (−33.3%; 95% CI, −44.7% to −19.6%; P Conclusions and Relevance Medical cannabis laws are associated with significantly lower state-level opioid overdose mortality rates. Further investigation is required to determine how medical cannabis laws may interact with policies aimed at preventing opioid analgesic overdose.
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TL;DR: Key features of DID designs are reviewed with an emphasis on public health policy research and it is noted that combining elements from multiple quasi-experimental techniques may be important in the next wave of innovations to the DID approach.
Abstract: The difference in difference (DID) design is a quasi-experimental research design that researchers often use to study causal relationships in public health settings where randomized controlled trials (RCTs) are infeasible or unethical. However, causal inference poses many challenges in DID designs. In this article, we review key features of DID designs with an emphasis on public health policy research. Contemporary researchers should take an active approach to the design of DID studies, seeking to construct comparison groups, sensitivity analyses, and robustness checks that help validate the method's assumptions. We explain the key assumptions of the design and discuss analytic tactics, supplementary analysis, and approaches to statistical inference that are often important in applied research. The DID design is not a perfect substitute for randomized experiments, but it often represents a feasible way to learn about casual relationships. We conclude by noting that combining elements from multiple quasi-experimental techniques may be important in the next wave of innovations to the DID approach.
789 citations
TL;DR: An overview of the changing US epidemiology of cannabis use and associated problems suggests national increases in cannabis potency, prenatal and unintentional childhood exposure; and in adults, increased use, CUD, cannabis-related emergency room visits, and fatal vehicle crashes.
405 citations
TL;DR: Suggestions are offered on cannabis-drug interactions, patient monitoring, and standards of care, while special cases for cannabis therapeutics are addressed: epilepsy, cancer palliation and primary treatment, chronic pain, use in the elderly, Parkinson disease, paediatrics, with concomitant opioids, and in relation to driving and hazardous activities.
392 citations
Cites result from "Medical Cannabis Laws and Opioid An..."
...This has been supported by basic science investigation [74], and a variety of observational studies [75–77] and epidemiological evidence of decreased opioid overdose mortality in US states with medical cannabis access [78], as well as lowered costs for analgesics including opioids in such states in the Medicare (elderly) [79] and Medicaid (low-income) [80] populations....
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Columbia University1, University of Malaya2, Yale University3, Central European University4, Johns Hopkins University5, RTI International6, University of California, San Francisco7, University of British Columbia8, Centro de Investigación y Docencia Económicas9, University of California, San Diego10, University of the Andes11, Human Rights Watch12, University of Uyo13, University of Bristol14, Charles University in Prague15
TL;DR: The Johns Hopkins-Lancet Commission on Drug Policy and Health as mentioned in this paper examined the emerging scientific evidence on public health issues arising from drug control policy and to inform and encourage a central focus on health evidence and outcomes in drug-policy debates, such as the important deliberations of the 2016 UNGASS on drugs.
365 citations
TL;DR: The factors that triggered the opioids crisis and its further evolution are analyzed, along with the interventions to manage and prevent opioid use disorder (OUD), which are fundamental for curtailing the opioid crisis.
Abstract: Importance More than 42 000 Americans died of opioid overdoses in 2016, and the fatalities continue to increase. This review analyzes the factors that triggered the opioid crisis and its further evolution, along with the interventions to manage and prevent opioid use disorder (OUD), which are fundamental for curtailing the opioid crisis. Observations Opioid drugs are among the most powerful analgesics but also among the most addictive. The current opioid crisis, initially triggered by overprescription of opioid analgesics, which facilitated their diversion and misuse, has now expanded to heroin and illicit synthetic opioids (fentanyl and its analogues), the potency of which further increases their addictiveness and lethality. Although there are effective medications to treat OUD (methadone hydrochloride, buprenorphine, and naltrexone hydrochloride), these medications are underused, and the risk of relapse is still high. Strategies to expand medication use and treatment retention include greater involvement of health care professionals (including psychiatrists) and approaches to address comorbidities. In particular, the high prevalence of depression and suicidality among patients with OUD, if untreated, contributes to relapse and increases the risk of overdose fatalities. Prevention interventions include screening and early detection of psychiatric disorders, which increase the risk of substance use disorders, including OUD. Conclusions and Relevance Although overprescription of opioid medications triggered the opioid crisis, improving opioid prescription practices for pain management, although important for addressing the opioid crisis, is no longer sufficient. In parallel, strategies to expand access to medication for OUD and improve treatment retention, including a more active involvement of psychiatrists who are optimally trained to address psychiatric comorbidities, are fundamental to preventing fatalities and achieving recovery. Research into new treatments for OUD, models of care for OUD management that include health care, and interventions to prevent OUD may further help resolve the opioid crisis and prevent it from happening again.
345 citations
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01 Jan 2009
TL;DR: The core methods in today's econometric toolkit are linear regression for statistical control, instrumental variables methods for the analysis of natural experiments, and differences-in-differences methods that exploit policy changes.
Abstract: The core methods in today's econometric toolkit are linear regression for statistical control, instrumental variables methods for the analysis of natural experiments, and differences-in-differences methods that exploit policy changes. In the modern experimentalist paradigm, these techniques address clear causal questions such as: Do smaller classes increase learning? Should wife batterers be arrested? How much does education raise wages? Mostly Harmless Econometrics shows how the basic tools of applied econometrics allow the data to speak. In addition to econometric essentials, Mostly Harmless Econometrics covers important new extensions--regression-discontinuity designs and quantile regression--as well as how to get standard errors right. Joshua Angrist and Jorn-Steffen Pischke explain why fancier econometric techniques are typically unnecessary and even dangerous. The applied econometric methods emphasized in this book are easy to use and relevant for many areas of contemporary social science. An irreverent review of econometric essentials A focus on tools that applied researchers use most Chapters on regression-discontinuity designs, quantile regression, and standard errors Many empirical examples A clear and concise resource with wide applications
7,192 citations
TL;DR: As marijuana use becomes legal in some states, the dominant public opinion is that marijuana is a harmless source of mood alteration, but enough information is available to cause concern.
Abstract: As marijuana use becomes legal in some states, the dominant public opinion is that marijuana is a harmless source of mood alteration. Although the harms associated with marijuana use have not been well studied, enough information is available to cause concern.
2,069 citations
TL;DR: The national cost of pain ranges from $560 to $635 billion, larger than the cost of the nation's priority health conditions and the annual cost of heart disease, cancer, and diabetes.
1,844 citations
"Medical Cannabis Laws and Opioid An..." refers background in this paper
...We also included 4 time-varying state-level factors: (1) the presence of a state-level prescription drug monitoring program (a state-level registry containing information on controlled substances prescribed in a state),16 (2) the presence of a law requiring or allowing a pharmacist to request patient identification before dispensing medications,17 (3) the presence of regulations establishing increased state oversight of pain management clinics,18 and (4) state- and year-specific unemployment rates to adjust for the economic climate....
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01 Jan 2011
TL;DR: Wide variation among states in the nonmedical use of OPR and overdose rates cannot be explained by underlying demographic differences in state populations but is related to wide variations in OPR prescribing.
Abstract: BACKGROUND
Overdose deaths involving opioid pain relievers (OPR), also known as opioid analgesics, have increased and now exceed deaths involving heroin and cocaine combined. This report describes the use and abuse of OPR by state.
METHODS
CDC analyzed rates of fatal OPR overdoses, nonmedical use, sales, and treatment admissions.
RESULTS
In 2008, drug overdoses in the United States caused 36,450 deaths. OPR were involved in 14,800 deaths (73.8%) of the 20,044 prescription drug overdose deaths. Death rates varied fivefold by state. States with lower death rates had lower rates of nonmedical use of OPR and OPR sales. During 1999--2008, overdose death rates, sales, and substance abuse treatment admissions related to OPR all increased substantially.
CONCLUSIONS
The epidemic of overdoses of OPR has continued to worsen. Wide variation among states in the nonmedical use of OPR and overdose rates cannot be explained by underlying demographic differences in state populations but is related to wide variations in OPR prescribing.
IMPLICATIONS FOR PUBLIC HEALTH PRACTICE
Health-care providers should only use OPRs in carefully screened and monitored patients when non-OPR treatments are insufficient to manage pain. Insurers and prescription drug monitoring programs can identify and take action to reduce both inappropriate and illegal prescribing. Third-party payers can limit reimbursement in ways that reduce inappropriate prescribing, discourage efforts to obtain OPR from multiple health-care providers, and improve clinical care. Changes in state laws that focus on the prescribing practices of health-care providers might reduce prescription drug abuse and overdoses while still allowing safe and effective pain treatment.
1,298 citations
TL;DR: Among patients receiving opioid prescriptions for pain, higher opioid doses were associated with increased risk of opioid overdose death, and receiving both as-needed and regularly scheduled doses was not associated with overdose risk after adjustment.
Abstract: Context The rate of prescription opioid–related overdose death increased substantially in the United States over the past decade. Patterns of opioid prescribing may be related to risk of overdose mortality. Objective To examine the association of maximum prescribed daily opioid dose and dosing schedule (“as needed,” regularly scheduled, or both) with risk of opioid overdose death among patients with cancer, chronic pain, acute pain, and substance use disorders. Design Case-cohort study. Setting Veterans Health Administration (VHA), 2004 through 2008. Participants All unintentional prescription opioid overdose decedents (n = 750) and a random sample of patients (n = 154 684) among those individuals who used medical services in 2004 or 2005 and received opioid therapy for pain. Main Outcome Measure Associations of opioid regimens (dose and schedule) with death by unintentional prescription opioid overdose in subgroups defined by clinical diagnoses, adjusting for age group, sex, race, ethnicity, and comorbid conditions. Results The frequency of fatal overdose over the study period among individuals treated with opioids was estimated to be 0.04%.The risk of overdose death was directly related to the maximum prescribed daily dose of opioid medication. The adjusted hazard ratios (HRs) associated with a maximum prescribed dose of 100 mg/d or more, compared with the dose category 1 mg/d to less than 20 mg/d, were as follows: among those with substance use disorders, adjusted HR = 4.54 (95% confidence interval [CI], 2.46-8.37; absolute risk difference approximation [ARDA] = 0.14%); among those with chronic pain, adjusted HR = 7.18 (95% CI, 4.85-10.65; ARDA = 0.25%); among those with acute pain, adjusted HR = 6.64 (95% CI, 3.31-13.31; ARDA = 0.23%); and among those with cancer, adjusted HR = 11.99 (95% CI, 4.42-32.56; ARDA = 0.45%). Receiving both as-needed and regularly scheduled doses was not associated with overdose risk after adjustment. Conclusion Among patients receiving opioid prescriptions for pain, higher opioid doses were associated with increased risk of opioid overdose death.
1,253 citations