Marijuana Law, Policy & Reform

Editor: Douglas A. Berman
Moritz College of Law

Friday, April 20, 2018

"Does medical marijuana decrease opioid use or boost it?"

The title of this post is the title of this effective new WonkBlog piece by Keith Humphreys, which makes these important points:

Studies conducted at the state level show that expanding access to medical marijuana is correlated with lower rates of opioid misuse and overdose.  Yet studies of individuals show that using medical cannabis is correlated with higher rates of using and misusing opioids.  This set of conflicting research has revealed less about the relationship between marijuana and opioids than it has about how science is misunderstood and misused in political debates....

The math underlying why many such apparent contradictions exist across scientific research areas is complicated, but the underlying point is simple: We can’t know what’s happening to individuals by looking just at state data (or county or city data), and we can’t know what is happening to states just by looking at individuals. Thus there isn’t any logical contradiction between marijuana and opioid use having opposite relationships at the state and individual level.

The other statistical point of relevance here is more widely understood: Just because two things are correlated doesn’t prove there’s a causal relationship between them. However, in this particular domain, people tend to apply that rule only to the subset of studies that conflict with their views on marijuana.  Sometimes this is a conscious decision by people who want to spin the evidence, but more often it reflects unconscious, built-in flaws in human reasoning that make us more prone to attend to and trust evidence that confirms what we already believe or deeply want to believe.  That is, people who hold anti-marijuana views will be more likely to accept the individual correlational studies as proving that medical cannabis is harmful and dismiss the state-level studies as “merely correlational.”  Those with positive views of marijuana will do the reverse.  (If you want to see this phenomenon in action, watch how this article is discussed on Twitter today!)

Being human, scientists also sometimes fall prey to the same problem, being too critical of marijuana studies that don’t accord with their beliefs and not critical enough of those that do.  But at their best, scientists design rigorous studies of important questions and then accept the answers whether they (or anyone else) likes them or not.

Solving the puzzle of whether and how medical cannabis and opioids interact will require laboratory experiments and randomized clinical trials in which researchers can control exposure to both drugs rather than relying on correlational data. In one recent such study, Ziva Cooper of Columbia University found initial evidence that marijuana may modify both the pain-relieving effects and abuse liability of oxycodone.

More studies like Cooper’s are needed and should become more common if Congress is wise enough to loosen restrictions on medical marijuana research. In the meantime, the medical marijuana debate will rage on, with many people on each side citing as authoritative whichever study suits their purposes.

April 20, 2018 in Medical community perspectives, Medical Marijuana Commentary and Debate, Medical Marijuana Data and Research | Permalink | Comments (0)

Monday, April 2, 2018

Two new papers provide further evidence of marijuana reform aiding with opioid crisis

180402-imd-ec-800As reported via this CNN article, headlined "Marijuana legalization could help offset opioid epidemic, studies find," this weeks bring the publication of notable new research suggesting a link between marijuana access and reduced use of opioids. Here are the basics:

Experts have proposed using medical marijuana to help Americans struggling with opioid addiction. Now, two studies suggest that there is merit to that strategy. The studies, published Monday in the journal JAMA Internal Medicine, compared opioid prescription patterns in states that have enacted medical cannabis laws with those that have not. One of the studies looked at opioid prescriptions covered by Medicare Part D between 2010 and 2015, while the other looked at opioid prescriptions covered by Medicaid between 2011 and 2016.

The researchers found that states that allow the use of cannabis for medical purposes had 2.21 million fewer daily doses of opioids prescribed per year under Medicare Part D, compared with those states without medical cannabis laws. Opioid prescriptions under Medicaid also dropped by 5.88% in states with medical cannabis laws compared with states without such laws, according to the studies....

In order to evaluate whether medical marijuana could function as an effective and safe alternative to opioids, the two teams of researchers looked at whether opioid prescriptions were lower in states that had active medical cannabis laws and whether those states that enacted these laws during the study period saw reductions in opioid prescriptions.

Both teams, in fact, did find that opioid prescriptions were significantly lower in states that had enacted medical cannabis laws. The team that looked at Medicaid patients also found that the four states that switched from medical use only to recreational use -- Alaska, Colorado, Oregon and Washington -- saw further reductions in opioid prescriptions, according to Hefei Wen, assistant professor of health management and policy at the University of Kentucky and a lead author on the Medicaid study. "We saw a 9% or 10% reduction (in opioid prescriptions) in Colorado and Oregon," Wen said. "And in Alaska and Washington, the magnitude was a little bit smaller but still significant."...

The details of the medical cannabis laws were found to have a significant impact on opioid prescription patterns, the researchers found. States that permitted recreational use, for example, saw an additional 6.38% reduction in opioid prescriptions under Medicaid compared with those states that permitted marijuana only for medical use, according to Wen.

The method of procurement also had a significant impact on opioid prescription patterns. States that permitted medical dispensaries -- regulated shops that people can visit to purchase cannabis products -- had 3.742 million fewer opioid prescriptions filled per year under Medicare Part D, while those that allowed only home cultivation had 1.792 million fewer opioid prescriptions per year.

"We found that there was about a 14.5% reduction in any opiate use when dispensaries were turned on -- and that was statistically significant -- and about a 7% reduction in any opiate use when home cultivation only was turned on," Bradford said. "So dispensaries are much more powerful in terms of shifting people away from the use of opiates."...

This is not the first time researchers have found a link between marijuana legalization and decreased opioid use. A 2014 study showed that states with medical cannabis laws had 24.8% fewer opioid overdose deaths between 1999 and 2010. A study in 2017 also found that the legalization of recreational marijuana in Colorado in 2012 reversed the state's upward trend in opioid-related deaths.

Here are links to the JAMA Internal Medicine articles referenced here, as well as a companion commentary:

Medical and Adult-Use Marijuana Laws and Opioid Prescribing for Medicaid Enrollees by Hefei Wen & Jason Hockenberry

Association Between US State Medical Cannabis Laws and Opioid Prescribing in the Medicare Part D Population by Ashley C. Bradford et al

The Role of Cannabis Legalization in the Opioid Crisis by Kevin Hill & Andrew Saxon

 

Some (of many) prior related posts:

April 2, 2018 in Medical community perspectives, Medical Marijuana Commentary and Debate, Medical Marijuana Data and Research, Medical Marijuana State Laws and Reforms, Recreational Marijuana Data and Research | Permalink | Comments (0)

Wednesday, March 28, 2018

Notable efforts to expand reach and application of New Jersey's medical marijuana program

Nj-mmj-e1522187420449The great state of New Jersey has been the focal point for a lot of interesting debate over recreational marijuana reform this year.  But as that debate continues, the state's new Governor has announced here a new effort to "expands patient access to medical marijuana."  Here are some details:

Governor Phil Murphy [Tuesday] announced major reforms to New Jersey’s Medicinal Marijuana Program. Reforms include the addition of medical conditions, lowered patient and caregiver fees, allowing dispensaries to add satellite locations, and proposed legislative changes that would increase the monthly product limit for patients, and allow an unlimited supply for those receiving hospice care.

“We are changing the restrictive culture of our medical marijuana program to make it more patient-friendly,” Governor Murphy said. “We are adding five new categories of medical conditions, reducing patient and caregiver fees, and recommending changes in law so patients will be able to obtain the amount of product that they need. Some of these changes will take time, but we are committed to getting it done for all New Jersey residents who can be helped by access to medical marijuana.”

More than 20 recommendations are outlined in a report that New Jersey Department of Health Commissioner Dr. Shereef Elnahal submitted to Governor Murphy in response to Executive Order 6, which directed a comprehensive review of the program within 60 days. “As a physician, I have seen the therapeutic benefits of marijuana for patients with cancer and other difficult conditions,” said Dr. Elnahal. “These recommendations are informed by discussions with patients and their families, advocates, dispensary owners, clinicians, and other health professionals on the Medicinal Marijuana Review Panel. We are reducing the barriers for all of these stakeholders in order to allow many more patients to benefit from this effective treatment option."

In the report, the Department submitted three categories of recommendations: those that are effective today, regulatory changes that will go through the rulemaking process, and proposals that require legislation. In addition, there are recommendations for important future initiatives to allow home delivery, develop a provider education curriculum, and expedite the permitting process. Effective today, five new categories of medical conditions (anxiety, migraines, Tourette’s syndrome, chronic pain related to musculoskeletal disorders, and chronic visceral pain) will be eligible for marijuana prescription. Currently, 18,574 patients, 536 physicians, and 869 caregivers participate in the program – a far smaller number than comparably populated states. The Commissioner will also be able to add additional conditions at his discretion.

Other immediate changes include lowering the biennial patient registration fee from $200 to $100 and adding veterans and seniors -- 65 and older -- to the list of those who qualify for the $20 discounted registration fee. Those on government assistance, including federal disability, already receive the reduced fee.

The report prepared by the New Jersey Department of Health is available at this link.

March 28, 2018 in Medical community perspectives, Medical Marijuana Commentary and Debate, Medical Marijuana Data and Research, Medical Marijuana State Laws and Reforms | Permalink | Comments (0)

"Enforcing Federal Drug Laws in States Where Medical Marijuana Is Lawful"

Jama-logoThe title of this post is the title of this  new Viewpoint commentary authored by Lawrence Gostin, James Hodge, and Sarah Wetter published earlier this week on line at JAMA. Here is how it concludes:

Toward Rational Medical Marijuana Policies

Although public opinion and state action have trended strongly toward permitting use of marijuana, especially for medical purposes, controversy continues to exist.  The specter of federal prosecution could refrain physicians, patients, and dispensaries from providing marijuana in states where the drug is lawful and dissuade additional jurisdictions from legalizing marijuana.  Public policy formed and implemented in the context of inconsistent federal and state laws, unpredictable legal enforcement, and insufficient scientific evidence is unsustainable.  Rational policies should follow a 3-pronged agenda.

A Solid Research Foundation

Sound policy requires a strong evidence base.  Scientific studies could quell ongoing disagreements about marijuana’s medical effectiveness, harms, and status as a gateway drug.  Yet limited funding and restrictive access to uniformly high-quality cannabis have sharply curtailed longitudinal studies on a drug already in wide use. Physicians require rigorous evidence to inform prescribing practices and counseling of patients.  At present, wide regional variations in prescribing practices exist, and patients do not have access to consistently high-quality, uncontaminated cannabis — where the purity, potency, and dosage can be ensured.  Health officials, moreover, rarely conduct careful surveillance of marijuana use incidence, prevalence, and outcomes.  Public policy on a potentially hazardous psychotropic drug is difficult when short- and long-term effects across populations are underreported, insufficiently studied, and poorly funded.

A Harmonized Legal Environment

Substantial variability of legal approaches to marijuana use exists across jurisdictions and between states and the federal government.  Individuals in certain jurisdictions can lawfully access marijuana for medical use, recreational use, or both, whereas individuals in other jurisdictions cannot do so.  Conditions under which physicians can prescribe (or patients can access) marijuana fluctuate extensively.  Federal law is inconsistent with policy in virtually all states.  The CSA should be revised to operate harmoniously with prevailing state law. Model legislation for medical use of marijuana, based on scientific evidence, could help reconcile activities across jurisdictions.

Federal Law Enforcement Respectful of States’ Sovereignty

Under US constitutional design, states and localities are laboratories for innovation, with state sovereignty and local home rule respected and preserved.  This requires federal prosecutorial discretion to hew to the legal environment of states that have legalized marijuana use.  Respecting marijuana laws is essential in states where cannabis is prescribed and used for medical purposes.  On an issue as consequential as marijuana, the nation needs consistent legal norms based on the best available scientific evidence.

March 28, 2018 in Criminal justice developments and reforms, Federal Marijuana Laws, Policies and Practices, Medical community perspectives, Medical Marijuana Commentary and Debate | Permalink | Comments (0)

Sunday, March 25, 2018

"Unique treatment potential of cannabidiol for the prevention of relapse to drug use: preclinical proof of principle"

Npp201754f1The title of this post is the title of this notable new research just published on-line from the journal Neuropsychopharmacology.  Here is the abstract:

Cannabidiol (CBD), the major non-psychoactive constituent of Cannabis sativa, has received attention for therapeutic potential in treating neurologic and psychiatric disorders. Recently, CBD has also been explored for potential in treating drug addiction.  Substance use disorders are chronically relapsing conditions and relapse risk persists for multiple reasons including craving induced by drug contexts, susceptibility to stress, elevated anxiety, and impaired impulse control.  Here, we evaluated the “anti-relapse” potential of a transdermal CBD preparation in animal models of drug seeking, anxiety and impulsivity.  Rats with alcohol or cocaine self-administration histories received transdermal CBD at 24 h intervals for 7 days and were tested for context and stress-induced reinstatement, as well as experimental anxiety on the elevated plus maze.

Effects on impulsive behavior were established using a delay-discounting task following recovery from a 7-day dependence-inducing alcohol intoxication regimen.  CBD attenuated context-induced and stress-induced drug seeking without tolerance, sedative effects, or interference with normal motivated behavior.  Following treatment termination, reinstatement remained attenuated up to ≈5 months although plasma and brain CBD levels remained detectable only for 3 days.  CBD also reduced experimental anxiety and prevented the development of high impulsivity in rats with an alcohol dependence history.  The results provide proof of principle supporting potential of CBD in relapse prevention along two dimensions CBD: beneficial actions across several vulnerability states, and long-lasting effects with only brief treatment. The findings also inform the ongoing medical marijuana debate concerning medical benefits of non-psychoactive cannabinoids and their promise for development and use as therapeutics.

I found this research via this press article with a headline that provides a crisp accounting of what this research means: "Cannabis drug may help alcohol and cocaine addicts overcome their cravings, study finds." Here is how one of the researchers explained the findings in the press account:

Speaking of the findings, lead author Dr Friedbert Weiss said: 'The efficacy of the CBD to reduce reinstatement in rats with both alcohol and cocaine -- and, as previously reported, heroin -- histories predicts therapeutic potential for addiction treatment across several classes of abused drugs.

'The results provide proof of principle supporting the potential of CBD in relapse prevention along two dimensions: beneficial actions across several vulnerability states and long-lasting effects with only brief treatment.

'Drug addicts enter relapse vulnerability states for multiple reasons. Therefore, effects such as these observed with CBD that concurrently ameliorate several of these are likely to be more effective in preventing relapse than treatments targeting only a single state.'

Results further suggest CBD is completely cleared from such rats' brains just three days after the treatment ends.

March 25, 2018 in Medical community perspectives, Medical Marijuana Commentary and Debate, Medical Marijuana Data and Research | Permalink | Comments (0)

Friday, March 23, 2018

Estimates of extraordinary health-care savings in research paper on medical marijuana laws and tobacco use

I just saw this notable research paper authored by Anna Choi, Dhaval Dave and Joseph Sabia under the title "Smoke Gets in Your Eyes: Medical Marijuana Laws and Tobacco Use." The last line of the abstract merits placement in bold because it is such a bold finding:

The public health costs of tobacco consumption have been documented to be substantially larger than those of marijuana use.  This study is the first to investigate the impact of medical marijuana laws (MMLs) on tobacco cigarette consumption . First, using data from the National Survey of Drug Use and Health (NSDUH), we establish that MMLs induce a 2 to 3 percentage-point increase in adult marijuana consumption, likely for both recreational and medicinal purposes.  Then, using data from the NSDUH, the Behavioral Risk Factor Surveillance System (BRFSS), and the Current Population Survey Tobacco Use Supplements (CPS-TUS), we find that the enactment of MMLs leads to a 1 to 1.5 percentage-point reduction in adult cigarette smoking.  We also find that MMLs reduce the number of cigarettes consumed by smokers, suggesting effects on both the cessation and intensive margins of cigarette use.  Our estimated effect sizes imply substantial MML-induced tobacco-related healthcare cost savings, ranging from $4.6 to $6.9 billion per year.

March 23, 2018 in Medical community perspectives, Medical Marijuana Commentary and Debate, Medical Marijuana Data and Research | Permalink | Comments (0)

Wednesday, March 7, 2018

"America Is Giving Away the $30 Billion Medical Marijuana Industry"

800x-1The title of this post is the headline of this notable lengthy new Bloomberg Businessweek article.  I am tempted to politicize this post by saying that a true "America First" President ought to be quite concerned about the sub-headline of this piece: "Why? Because the feds are bogarting the weed, while Israel and Canada are grabbing market share."  I recommend the piece in full, and here are excerpts:

Lyle Craker is an unlikely advocate for any political cause, let alone one as touchy as marijuana law, and that’s precisely why Rick Doblin sought him out almost two decades ago. Craker, Doblin likes to say, is the perfect flag bearer for the cause of medical marijuana production—not remotely controversial and thus the ideal partner in a long and frustrating effort to loosen the Drug Enforcement Administration’s chokehold on cannabis research. There are no counterculture skeletons in Craker’s closet; only dirty boots and botany books. He’s never smoked pot in his life, nor has he tasted liquor. “I have Coca-Cola every once in a while,” says the quiet, white-haired Craker, from a rolling chair in his basement office at the University of Massachusetts at Amherst, where he’s served as a professor in the Stockbridge School of Agriculture since 1967, specializing in medicinal and aromatic plants. He and his students do things such as subject basil plants to high temperatures to study the effects of climate change on what plant people call the constituents, or active elements....

In June 2001, Craker filed an application for a license to cultivate “research-grade” marijuana at UMass, with the goal of staging FDA-approved studies. Six months later he was told his application had been lost. He reapplied in 2002 and then, after an additional two years of no action, sued the DEA, backed by MAPS. By this point, both U.S. senators from Massachusetts had publicly supported his application, and a federal court of appeals ordered the DEA to respond, which it finally did, denying the application in 2004.

Craker appealed that decision with backing from a powerful bench of allies, including 40 members of Congress, and finally, in February 2007, a DEA administrative law judge ruled that his application for a license should be granted. The decision was not binding, however; it was merely a recommendation to the DEA leadership. Almost two years later, in the last week of the Bush administration, the application was rejected. Craker threw up his hands. He firmly believed marijuana should be more widely grown and studied, but he’d lost any hope that it would happen in his lifetime. And he had basil to attend to.

Then, in August 2016, during the final months of the Obama presidency, the DEA reversed course. It announced that, for the first time in a half-century, it would grant new licenses. Doblin, who has seemingly endless supplies of optimism and enthusiasm, convinced the professor there was hope—again. So Craker submitted paperwork, again, along with 25 other groups. The university’s provost co-signed his application, and Senator Elizabeth Warren (D–Mass.) wrote a letter to the DEA in support of his effort. He’s still waiting to hear back. “I’m never gonna get the license,” Craker says.

Pessimism isn’t surprising from a man who’s been making a reasonable case for 17 years to no avail. Studies around the world have shown that marijuana has considerable promise as a medicine. Craker says he spoke late last year at a hospital in New Hampshire where certain cannabinoids were shown to facilitate healing in brain-damaged mice. “And I thought, ‘If cannabinoids could do that, let’s put them in medicines!’ ” He sighs. “We can’t do the research.”

Another sigh. “I’m naive about a lot about things,” he says. “But it seems to me that we should be looking at cannabis. I mean, if it’s going to kill people, let’s know that and get rid of it. If it’s going to help people, let’s know that and expand on it. … But there’s just something wrong with the DEA. I don’t know what else to say. … Somehow, marijuana’s got a bad name. And it’s tough to let go of.”....

Many people expect the Republican-controlled Congress to follow its recent tax overhaul by looking for ways to slash costs in Medicaid and Medicare. Legitimate research into the medicinal properties of marijuana could help. Studies show that opioid use drops significantly in states where marijuana has been legalized; this suggests people are consuming the plant for pain, something they could be doing more effectively if physicians and the FDA controlled chemical makeup and potency. A study published in July 2016 in Health Affairs showed that the use of prescription drugs for which marijuana could serve as a clinical alternative “fell significantly,” saving hundreds of millions of dollars among users of Medicare Part D....

Among those who’ve advised Craker is Tony Coulson, a former DEA agent who retired in 2010 and works as a consultant for companies developing drugs. Coulson was vehemently antimarijuana until his son, a combat soldier, came home from the Middle East with post-traumatic stress disorder and needed help. “For years I was of the belief that the science doesn’t say that this is medicine,” he says. “But when you get into this curious history, you find the science doesn’t show it primarily because we’re standing in the way. The NIDA monopoly prevents anyone from getting into further studies.”

Coulson blames the Obama administration for not acting sooner, creating a situation in which the decision on granting new growing licenses was passed down to Attorney General Jeff Sessions, who has publicly declared his belief in the dangers of marijuana. The NIDA monopoly is now his to change. “Sessions has a 1930s Reefer Madness view of the marijuana world,” Coulson says. “It’s not realistic, and it’s not what rank-and-file DEA really are concerned about. DEA folks have moved beyond this.”

“I guess I take a nationalist approach here,” says Rick Kimball, a former investment banker who’s raising money for a marijuana-related private equity fund and is a trustee for marijuana policy at the Brookings Institution. “We have a huge opportunity in the U.S.,” he says, “and we ought to get our act together. I’m worried that we’re ceding this whole market to the Israelis.”

March 7, 2018 in Business laws and regulatory issues, Federal Marijuana Laws, Policies and Practices, Medical community perspectives, Medical Marijuana Commentary and Debate, Medical Marijuana Data and Research, Who decides | Permalink | Comments (0)

Monday, March 5, 2018

Encouraging research from Minnesota on success of medical marijuana in the treatment of "intractable pain"

Download (9)This recent press release from the Minnesota Department of Health, headlined "Medical cannabis study shows significant number of patients saw pain reduction of 30 percent or more," provides a summary of this encouraging lengthy report titled "Intractable Pain Patients in the Minnesota Medical Cannabis Program: Experience of Enrollees During the First Five Months." Here is the start of the press release:

Forty-two percent of Minnesota’s patients taking medical cannabis for intractable pain reported a pain reduction of thirty percent or more, according to a new study conducted by the Minnesota Department of Health. “This study helps improve our understanding of the potential of medical cannabis for treating pain,” said Minnesota Health Commissioner Jan Malcolm. “We need additional and more rigorous study, but these results are clinically significant and promising for both pain treatment and reducing opioid dependence.”

The first-of-its-kind research study is based on the experiences of the initial 2,245 people enrolled for intractable pain in Minnesota’s medical cannabis program from August 1, 2016 to December 31, 2016. Of this initial group, 2,174 patients purchased medical cannabis within the study’s observation period and completed a required self-evaluation before each purchase.

As part of the self-evaluation, patients completed the PEG (pain, enjoyment and general activity) screening tool. On a scale of 0 to 10 (with 0 being no pain and 10 being the highest pain), patients rated their level of pain, how pain interfered with their enjoyment of life and how pain interfered with their general activity.

Using the PEG scale data, 42 percent of the patients who scored moderate to high pain levels at the beginning of the measurement achieved a reduction in pain scores of 30 percent or more, and 22 percent of patients both achieved and maintained a reduction of 30 percent or more over four months. The 30 percent reduction threshold is often used in pain studies to define clinically meaningful improvement. Health care practitioners caring for program-enrolled patients suffering from intractable pain reported similar reductions in pain scores, saying 41 percent of patients achieved at least a reduction of 30 percent or more.

The study also found that of the 353 patients who self-reported taking opioid medications when they started using medical cannabis, 63 percent or 221 reduced or eliminated opioid use after six months. Likewise, the health care practitioner survey found that 58 percent of patients who were on other pain medications were able to reduce their use of these medications when they started taking medical cannabis. Thirty-eight percent of patients reduced opioid medication (nearly 60 percent of these cut use of at least one opioid by half or more), 3 percent of patients reduced benzodiazepines and 22 percent of patients reduced other pain medications.

The safety profile of medical cannabis products available through the Minnesota program continues to appear favorable. No serious adverse events (life threatening or requiring hospitalization) were reported for this group of patients during the observation period. 

Here is a portion of the executive summary from the full report:

Among respondents to the patient (54% response rate) and health care practitioner (40% response rate) surveys, a high level of benefit was reported by 61% and 43%, respectively (score of 6 or 7 on a seven-point scale). Little or no benefit (score of 1, 2, or 3) was reported by 10% of patients and 24% of health care practitioners.

The benefits extended beyond reduction in pain severity, though that was the benefit mentioned most often (64%). The benefit described second most often was improved sleep (27%), which likely has a synergistic relationship with reduction in pain severity. In some cases improved sleep, reduction of other pain medications and their side effects, decreased anxiety, improved mobility and function, and other quality of life factors were cited as being the most important benefit. The pattern of described benefits was similar in the patient and the health care practitioner survey results....

A large proportion (58%) of patients on other pain medications when they started taking medical cannabis were able to reduce their use of these meds according to health care practitioner survey results. Opioid medications were reduced for 38% of patients (nearly 60% of these reduced at least one opioid by ≥50%), benzodiazepines were reduced for 3%, and other pain medications were reduced for 22%. If only the 353 patients (60.2%, based on medication list in first Patient Self-Evaluation) known to be taking opioid medications at baseline are included, 62.6% (221/353) were able to reduce or eliminate opioid usage after six months.

March 5, 2018 in Medical community perspectives, Medical Marijuana Commentary and Debate, Medical Marijuana Data and Research, Medical Marijuana State Laws and Reforms | Permalink | Comments (0)

Wednesday, February 28, 2018

Americans for Safe Access releases its latest analysis and report card on medical marijuana programs across United States

Asa_default_social_thumbnail2The advocacy group Americans for Safe Access regularly produces reports on the state of state medical marijuana laws, and this latest 2018 version of ASA's “Medical Marijuana Access in the United States: A Patient-Focused Analysis of the Patchwork of State Laws” now runs almost 200 pages.  I recommend the report in full for everyone interested in medical marijuana information, and here is part of the report's preface:

For over fifteen years, Americans for Safe Access (ASA) has engaged state and federal governments, courts, and regulators to improve the development and implementation of state medical cannabis laws and regulations.  This experience has taught us how to assess whether or not state laws meet the practical needs of patients. It has also provided us with the tools to advocate for programs that will better meet those needs. Passing a medical cannabis law is only the first step in a lengthy implementation process, and the level of forethought and advance input from patients can make the difference between a well-designed program and one that is seriously flawed.  One of the most important markers of a well-designed program is whether or not all patients who would benefit from medical cannabis will have safe and legal access to their medicine without fear of losing any of the civil rights and protections afforded to them as American citizens....

Today, we have a patchwork of medical cannabis laws across the United States.  Thirty states, the District of Columbia, Guam, and Puerto Rico have adopted laws that created programs that allow at least some patients legal access to medical cannabis.  Most of those thirty states provide patients with protections from arrest and prosecution as well as incorporate a regulated production and distribution program.  Several programs also allow patients and their caregivers to cultivate a certain amount of medical cannabis themselves.  While it took a long time for states to recognize the importance of protecting patients from civil discrimination (employment, parental rights, education, access to health care, etc.), more and more laws now include these explicit protections.

However, as of 2017, none of the state laws adopted thus far can be considered ideal from a patient’s standpoint.  Only a minority of states currently include the entire range of protections and rights that should be afforded to patients under the law, with some lagging far behind others.  Because of these differences and deficiencies, patients have argued that the laws do not function equitably and are often poorly designed, implemented, or both.  As production and distribution models are implemented, hostile local governments have found ways to ban such activity, leaving thousands of patients without the access state law was intended to create. Minnesota, for example, despite setting up a regulatory system for the production, manufacturing, and distribution of cannabis oil extracts, prohibits qualified patients from using the actual plant.  These laws include sanctions for qualified patients who seek to use their medicine in whole plant form, unnecessarily eliminating clinically validated routes of administration used by hundreds of thousands of patients.  Some states have taken years to implement their medical cannabis laws leaving patients waiting years before their medicine is available. 

February 28, 2018 in History of Marijuana Laws in the United States, Medical community perspectives, Medical Marijuana Commentary and Debate, Medical Marijuana Data and Research, Medical Marijuana State Laws and Reforms | Permalink | Comments (0)

Monday, February 5, 2018

Still more research "suggesting broader access to medical marijuana facilitates substitution of marijuana for powerful and addictive opioids"

S01676296The March 2018 issue of the Journal of Health Economics includes this new research article that provides still further support for a claim that greater access to marijuana may be able to play a role in reducing use and abuse of opioids.  The new article is authored by David Powell, Rosalie Liccardo Pacula and Mireille Jacobson under the title "Do medical marijuana laws reduce addictions and deaths related to pain killers?".  Here is its abstract:

Recent work finds that medical marijuana laws reduce the daily doses filled for opioid analgesics among Medicare Part-D and Medicaid enrollees, as well as population-wide opioid overdose deaths.  We replicate the result for opioid overdose deaths and explore the potential mechanism.  The key feature of a medical marijuana law that facilitates a reduction in overdose death rates is a relatively liberal allowance for dispensaries.  As states have become more stringent in their regulation of dispensaries, the protective value generally has fallen.  These findings suggest that broader access to medical marijuana facilitates substitution of marijuana for powerful and addictive opioids.

Some (of many) prior related posts:

February 5, 2018 in Medical community perspectives, Medical Marijuana Data and Research | Permalink | Comments (0)

Wednesday, December 27, 2017

Some new particulars on what West Virginia physicians think about medical marijuana

In this post last week, I noted the notable data from a survey of West Virginia physicians. The state's Department of Health and Human Resources found that, of "1,455 physicians who took the online survey, 82 percent of them indicated their interest in medical marijuana." Now I see this new local article, headlined "WV State Medical Association drills down on medical marijuana survey," reporting on a smaller survey conducted by the West Virginia State Medical Association. Here are a few details:

Medical Association President Dr. Brad Henry tells MetroNews the organization’s survey of its members show results not nearly as high as the state online survey that showed 82 percent of state doctors “interested” in medical marijuana.

In the WVSMA survey, in which approximately 75 doctors participated, only 31 percent said they were interested in becoming a certified physician for the state’s new medical marijuana law set to take effect in 2019. Henry said the issue continues to be the lack of research associated with the medicinal use of the drug. “Every time I read anything, anything that comes out, there’s some promise but there’s still aren’t good scientific studies to support marijuana use for anything,” Henry said. “There still isn’t that level of scientific information to at least give me confidence in the utility of it as a medicine.”

One thing the doctors are struggling with is the provision in the law that would have a doctor certify someone that has a diagnosis but there’s much else they can tell them because of the lack of research on the drug, Henry said. “You can’t look up (medical marijuana) in a textbook and say, ‘Okay, this is how much you should use. This is the side effects you should expect.’ Even over-the-counter (drugs) you can find what the usual dosages are and what the usual side effects are but with this substance (medical marijuana) that’s just not available,” Henry said....

Four of the questions in the medical association’s survey:

– Do you think there is scientific evidence to support marijuana use as a medical treatment?  Yes 65 percent

– Do you believe the legal access to medical marijuana will help patients?  Yes 64 percent

– Are you interested in becoming a certified physician?  Yes 31 percent

– Are you willing to receive the training required for the certification?  Yes 34 percent

December 27, 2017 in Medical community perspectives, Medical Marijuana Commentary and Debate, Medical Marijuana Data and Research, Who decides | Permalink | Comments (0)

Thursday, December 21, 2017

Notable coverage of notable marijuana reform public health issues in Nov 2017 issue of Preventive Medicine

1-s2_0-S0091743517X00108-cov150hI have just seen that the November 2017 issue of Preventive Medicine has a series of articles on the "potential health impacts of legalizing recreational marijuana use," and that series is described in an editorial introduction this way:

Legalization of marijuana use has gained considerable momentum in the U.S. with 28 states plus the District of Columbia (DC) legalizing medical marijuana use and 8 states plus DC legalizing recreational marijuana use, with similar liberalization of laws occurring in Canada and other countries (NYTimes, April 13, 2017).  Such actions clearly have tremendous public health implications and it is important that those implications be considered using the best available scientific evidence.

In this Special Issue we invited policy makers from Colorado (Ghosh et al., 2017, in this issue), the first U.S. state to legalize recreational marijuana use, Vermont (Chen and Searles, 2017, in this issue), a state currently considering legalization of recreational use, and the U.S.’s National Institute on Drug Abuse (Weiss and Wargo, 2017, in this issue) to provide a federal perspective on the health implications of legalizing recreational marijuana use.

In addition to policy makers we invited contributions from scientific experts in the health impacts of marijuana use to address the implications of legalizing recreational marijuana use, including potential impacts on the epidemiology of marijuana use and risk perceptions among youth and adults (Carliner et al., 2017, in this issue), emergency medicine (Wang et al., 2017, in this issue), addiction risk (Budney and Borodovsky, 2017, in this issue), adolescent risks and potential interventions (Schuster et al., 2017; Walker, 2017, in this issue), and maternal and child health (Mark and Terplan, 2017, in this issue).

Here are just some of the titles of some of the notable article in the issue:

  • "Lessons learned after three years of legalized, recreational marijuana: The Colorado experience"
  • "Cannabis use, attitudes, and legal status in the U.S.: A review"
  • "Marijuana and acute health care contacts in ColoradoOriginal Research Article" 
  • "The potential impact of cannabis legalization on the development of cannabis use disorders"
  • "Legalization of cannabis: Considerations for intervening with adolescent consumers"

December 21, 2017 in Medical community perspectives, Recreational Marijuana Commentary and Debate, Recreational Marijuana Data and Research, Recreational Marijuana State Laws and Reforms | Permalink | Comments (0)

Monday, December 18, 2017

New data from West Virginia showing strong physician interest in state's developing medical marijuana program

As reported in this local article, headlined "Survey: 82 percent of WV doctors 'interested' in medical marijuana," a notably large percentage of surveyed physicians have expressed an interest in an emerging medical marijuana regime. Here are the basics:

An overwhelming majority of surveyed West Virginia physicians are “interested” in medical cannabis, according to the Department of Health and Human Resources.  Of 1,455 physicians who took the online survey, 82 percent of them indicated their interest in medical marijuana, which will be legal in the state in July 2019 thanks to a law passed during the last legislative session.

Dr. Rahul Gupta, state health officer and commissioner of the state Bureau for Public Health, said the high response volume gives the state a sound outlook on patient and physician views of the looming change.  “We found that to be compelling that there is a certain level of interest, not just from patients, but from the physician community,” he said.

Along with doctors, the bureau analyzed survey results from 6,003 West Virginians, as well as Public Employees Insurance Agency and Medicaid claim data to tease out what tweaks, if any, might be needed for the nascent program.  Of the patients who responded, 2,120 reported suffering from chronic pain, 1,579 reported suffering from post-traumatic stress disorder and another 980 reported suffering from a mental health disorder.

The Medicaid and PEIA data shows crossover between some of the most prevalent conditions in the state and the list of conditions whose victims qualify to obtain medical marijuana....

There is still work to be done and change for the organization to consider.  Among the questions Gupta said the board is considering: Should the state limit how many dispensaries can obtain a permit to sell?  Should the board approve the sale of marijuana in plant form?  Should patients be allowed to grow their own marijuana plants? Should patients be able to purchase any other forms of marijuana?

Marijuana will be available to certified patients in the form of a pill, oil, topical, via vaporization or nebulization, tincture, liquid, or dermal patch.  Gupta said the board is scheduled to meet again in February.

December 18, 2017 in Medical community perspectives, Medical Marijuana Data and Research, Medical Marijuana State Laws and Reforms, Who decides | Permalink | Comments (0)

Saturday, December 9, 2017

"Medical Pot Is Our Best Hope to Fight the Opioid Epidemic"

Images (3)The title of this post is the headline of this new Rolling Stone article. Here are excerpts (with some links from the original preserved):

The pain-relieving properties of cannabis are no longer hypothetical or anecdotal. At the beginning of the year, the National Academies of Science, Medicine and Engineering released a landmark report determining that there is conclusive evidence that cannabis is effective in treating chronic pain.  What's even more promising is that early research indicates that the plant not only could play a role in treating pain, but additionally could be effective in treating addiction itself – meaning marijuana could actually be used as a so-called "exit drug" to help wean people off of pills or heroin.

"We're not just saying opioids make you feel good and so does cannabis, and now you're addicted to cannabis. There are direct reasons why this could actually help people get off of opioids," says Jeff Chen, director of UCLA's new Cannabis Research Initiative.  "If there is a chronic pain component, the cannabis can address the chronic pain component. We also find opioid addicts have a lot of neurological inflammation, which we believe is driving the addictive cycle. We see in preliminary studies that cannabinoids can reduce neurological inflammation, so cannabis could be directly addressing the inflammation in the brain that's leading to opioid dependency."

The theory that cannabinoids could decrease cravings for opioids is further supported by a small 2015 study published in the journal Neurotherapeutics, which found that the non-psychoactive cannabinoid CBD was effective in reducing the desire for heroin among addicts, and remained effective for an entire week after being administered. Similar effects have long been observed in animal studies.

Cannabis, in fact, may be exactly the kind of opioid replacement that politicians and pharmaceutical executives claim to be searching for. "I will be pushing the concept of non-addictive painkillers very, very hard," President Trump said in October, when declaring opioid abuse a national public health emergency.  The CEO of Purdue Pharma, which makes OxyContin, recently referred to the possibility of a drug that helps with pain but isn't physically addictive as the "Holy Grail."...

But already, many Americans seem to be replacing their pills with pot. A survey of pain patients in Michigan, published in 2016 in the journal of the American Pain Society, found medical cannabis use was associated with a 64 percent decrease in opioid use.  A 2016 study published in the health policy journal Health Affairs found that states with medical marijuana saw a drop in Medicare prescriptions and spending for conditions that are commonly treated with cannabis, including chronic pain, glaucoma, seizures and sleep disorders. And a 21-month study of 66 chronic pain patients using prescription opioids in New Mexico found that those enrolled in the state's medical cannabis program were 17 times more likely to quit opioids than those who were not.

At the same time, opioid-related deaths and overdose treatment admissions appear to be declining by nearly 25 percent in states where patients have access to legal marijuana. That number comes primarily from a 2014 study in the Journal of the American Medical Association, and has been supported by additional data from the American Journal of Public Health, the American Academy of Nursing, and the Journal of Drug and Alcohol Dependence.

However, more research is sorely needed. Stanford professor and drug policy expert Keith Humphreys described the studies concerning cannabis legalization and the decrease in opioid-related deaths and hospital admissions as falling victim to a form of logical error known as ecological fallacy. "It's correlation, not causation," he told me, because you cannot use statistical information about entire populations to understand individual behavior.

And researchers are eager for more solid evidence.  The Cannabis Research Initiative at UCLA is working on establishing one of the first studies that will directly administer cannabis to patients addicted to opioids, potentially providing a much more comprehensive understanding of how this all works. Chen, the initiative director, says he has scientists, clinics and a study design all lined up, but funding has been a struggle. "You're forced to go an extra ten miles with zero gas in the tank when it comes to cannabis research," he says. Between the lack of support from the federal government and pharmaceutical companies, Chen says he is "pretty much dependent on philanthropy."

Some (of many) prior related posts:

December 9, 2017 in Medical community perspectives, Medical Marijuana Commentary and Debate, Medical Marijuana Data and Research, Medical Marijuana State Laws and Reforms | Permalink | Comments (0)

Sunday, November 26, 2017

Taking a close look at "Big Pharma's Anti-Marijuana Campaign"

As mentioned in a prior post, my Marijuana Law, Policy & Reform seminar is hitting its homestretch and the last group of students are delivering presentations on a marijuana-related topic of their choosing. One student for the next class will be looking at what she is calling "Big Pharma's Anti-Marijuana Campaign."  Here is how she has explained her plans, following by links to background information regarding the topic:

My presentation will reveal how Big Pharma contributes to the Opioid Epidemic, how marijuana can be used as a substitute for opioids, how the legalization of medical marijuana threatens the bottom lines of pharmaceutical giants, and how these corporations have subsequently opposed pro-pot legislation.

NIH data on "Overdose Death Rates"

"Can Medical Marijuana Help End the Opioid Epidemic?"

"Patients Are Ditching Opioid Pills for Weed: Can marijuana help solve the opioid epidemic?"

"Is Big Pharma Out to Stop — Or Take Over — Marijuana Legalization?"

"The Real Reason Pot Is Still Illegal: Opponents of marijuana-law reform insist that legalization is dangerous — but the biggest threat is to their own bottom line."

November 26, 2017 in Business laws and regulatory issues, Medical community perspectives, Medical Marijuana Commentary and Debate, Recreational Marijuana Commentary and Debate, Who decides | Permalink | Comments (0)

Sunday, November 19, 2017

Still more talk, from notable conservative outlets, about possible benefits of marijuana reform amidst opioid crisis

Regular readers know that many proponents of marijuana reform have been eager in recent years to talk up the possible benefits of marijuana reform as one useful response to the on-going opioid crisis.   Indeed, since I have blogged many stories and commentaries on this front, it is not really big news to see more new advocacy along these lines.  But that said, this past week I have seen these two notable commentaries in this vein appearing in notable conservative or right-leaning outlets:

From the American Conservative here by Jeffrey Singer, "Can Marijuana Help Addicts Kick Opioids?: Research shows this once maligned 'gateway' drug could be an off-ramp."

From the Wall Street Journal here by Richard Boxer, "Can Marijuana Alleviate the Opioid Crisis?: The federal government should stop blocking research into the drug’s medical potential."

Some (of many) prior related posts:

November 19, 2017 in Medical community perspectives, Medical Marijuana Commentary and Debate | Permalink | Comments (0)

Thursday, November 16, 2017

"Pediatric Death Due to Myocarditis After Exposure to Cannabis"

Advocates of marijuana reform are often quick to assert that nobody dies from an overdose of marijuana.  But this new clinical report from two Colorado doctors, which has the same title as this post, discusses a case of an 11-month child who may have died as a direct result of marijuana exposure.   The paper is authored by Thomas Nappe and Christopher Hoyte, and here is the paper's abstract:

Since marijuana legalization, pediatric exposures to cannabis have increased.  To date, pediatric deaths from cannabis exposure have not been reported.  The authors report an 11-month-old male who, following cannabis exposure, presented with central nervous system depression after seizure, and progressed to cardiac arrest and died.  Myocarditis was diagnosed post-mortem and cannabis exposure was confirmed.  Given the temporal relationship of these two rare occurrences – cannabis exposure and sudden death secondary to myocarditis in an 11-month-old – as well as histological consistency with drug-induced myocarditis without confirmed alternate causes, and prior reported cases of cannabis-associated myocarditis, a possible relationship exists between cannabis exposure in this child and myocarditis leading to death. In areas where marijuana is commercially available or decriminalized, the authors urge clinicians to preventively counsel parents and to include cannabis exposure in the differential diagnosis of patients presenting with myocarditis.

UPDATE: Unsurprisingly, this clinical report links a death to marijuana exposure has created a stir, and this new Washington Post piece headlined "The truth behind the ‘first marijuana overdose death’" provides some context for the controversy.

November 16, 2017 in Medical community perspectives, Medical Marijuana Data and Research, Recreational Marijuana Data and Research | Permalink | Comments (4)

Monday, November 13, 2017

A reasonable accounting of public health realities surrounding marijuana and alcohol

ALCOHOL-VS-MARIJUANA-INFO-CROPThis new Business Insider article, headlined "We took a scientific look at whether weed or alcohol is worse for you — and there appears to be a winner," provides a pretty reasonable review of basic public health research concerning marijuana and alcohol. Here is how the article starts, its main boldheadings, and it conclusion:

Which is worse for you: weed or whiskey? It's a tough call, but based on the science, there appears to be a clear winner.

Keep in mind that there are dozens of factors to account for, including how the substances affect your heart, brain, and behavior, and how likely you are to get hooked. Time is important, too — while some effects are noticeable immediately, others only begin to shape up after months or years of use.

The comparison is slightly unfair for another reason: While scientists have been researching the effects of alcohol for decades, the science of cannabis is a lot murkier due to its mostly illegal status.

30,722 Americans died from alcohol-induced causes in 2014. There have been 0 documented deaths from marijuana use alone. ...

Marijuana appears to be significantly less addictive than alcohol. ...

Marijuana may be harder on your heart; while moderate drinking could be beneficial....

Alcohol is strongly linked with several types of cancer; marijuana is not....

Both drugs may be linked with risks while driving, but alcohol is worse. ...

Several studies link alcohol with violence, particularly at home. That has not been found for cannabis. ...

Both drugs negatively impact your memory, but in different ways. These effects are the most common in heavy, frequent, or binge users. ...

Both drugs are linked with an increased risk of psychiatric disease. For weed users, psychosis and schizophrenia are the main concern; with booze, it's depression and anxiety....

Alcohol appears to be linked more closely with weight gain than marijuana, despite weed's tendency to trigger the munchies. ...

All things considered, alcohol's effects seem markedly more extreme — and risky — than marijuana's.

When it comes to their addiction profile and their risk of death or overdose combined with their ties to cancer, car crashes, violence, and obesity, the research suggests that marijuana may be less of a health risk than alcohol.

Still, because of marijuana's largely illegal status, long-term studies on all of its health effects have been limited — meaning that more research is desperately needed.

November 13, 2017 in Food and Drink, Medical community perspectives, Medical Marijuana Commentary and Debate, Recreational Marijuana Commentary and Debate | Permalink | Comments (0)

Saturday, November 11, 2017

Lots of headlines (and prior posts) about veterans having access to medical marijuana ... but work remains in Trump era

Veterans-day-thank-you-quotesRegular readers know I have, since starting this blog more than four years ago, regularly blogged about a range of issues relating to veterans and their access to marijuana (a dozen of my more recent posts on this topic are linked below).  I feel a genuine and deep debt to anyone and everyone who serves this nation through the armed forces, and I feel  strongly that veterans should be able to have safe and legal access to any and every form of medicine that they and their doctors reasonably believe could help them with any ailments or conditions.

Notably, this White House release from a few days ago touts "President Donald J. Trump is Putting Our Veterans First," and it quotes Prez Trump sating that "we will not rest until all of America’s great veterans can receive the care they so richly deserve."  But current federal law essentially puts veterans last, not first, when it comes to access to medical marijuana because doctors with the Veterans Administration are legally barred from providing the recommendations that patients needs to obtain medical marijuana under state laws.

Perhaps unsurprisingly, on this Veterans Day 2017, issues relating to veterans and their access to marijuana are getting ever more attention.  Here are a few recent press pieces that caught my eye on this topic, followed by a lot of prior posts:

Some recent prior related posts:

November 11, 2017 in Federal Marijuana Laws, Policies and Practices, Medical community perspectives, Medical Marijuana Commentary and Debate, Who decides | Permalink | Comments (0)

Wednesday, October 11, 2017

"The use of cannabis in response to the opioid crisis: A review of the literature"

Cov200hThe title of this post is the title of this notable short literature review on a topic that regular readers know I find very interesting.  The article by multiple authors appears in Nursing Outlook, which is the official journal of the American Academy of Nursing.  Here is its abstract:

Background

A staggering number of Americans are dying from overdoses attributed to prescription opioid medications (POMs).  In response, states are creating policies related to POM harm reduction strategies, overdose prevention, and alternative therapies for pain management, such as cannabis (medical marijuana).  However, little is known about how the use of cannabis for pain management may be associated with POM use.

Purpose

The purpose of this article is to examine state medical cannabis (MC) use laws and policies and their potential association with POM use and related harms.

Methods

A systematic literature review was conducted to explore United States policies related to MC use and the association with POM use and related harms. Medline, PubMed, CINAHL, and Cochrane databases were searched to identify peer-reviewed articles published between 2010 and 2017. Using the search criteria, 11,513 records were identified, with 789 abstracts reviewed, and then 134 full-text articles screened for eligibility.

Findings

Of 134 articles, 10 articles met inclusion criteria. Four articles were cross-sectional online survey studies of MC substitution for POM, six were secondary data analyses exploring state-level POM overdose fatalities, hospitalizations related to MC or POM harms, opioid use disorder admissions, motor vehicle fatalities, and Medicare and Medicaid prescription cost analyses.  The literature suggests MC laws could be associated with decreased POM use, fewer POM-related hospitalizations, lower rates of opioid overdose, and reduced national health care expenditures related to POM overdose and misuse.  However, available literature on the topic is sparse and has notable limitations.

Conclusions

Review of the current literature suggests states that implement MC policies could reduce POM-associated mortality, improve pain management, and significantly reduce health care costs. However, M C research is constrained by federal policy restrictions, and more research related to MC as a potential alternative to POM for pain management, MC harms, and its impact on POM-related harms and health care costs should be a priority of public health, medical, and nursing research.

Some (of many) prior related posts:

October 11, 2017 in Medical community perspectives, Medical Marijuana Commentary and Debate, Medical Marijuana Data and Research | Permalink | Comments (0)