Marijuana Law, Policy & Reform

Editor: Douglas A. Berman
Moritz College of Law

Monday, March 25, 2019

"The Effect of Marijuana Use on American Veterans with PTSD, and How the U.S. Department of Veterans Affairs Ought to Respond"

The title of this post is the title of a presentation to be made by one of my students in my Marijuana Law, Policy & Reform seminar this coming week.  Here is part of his explanation of his topic and links to some background reading:

Because the U.S. Department of Veterans Affairs (VA) is required to follow all federal laws, the VA is prohibited from prescribing, recommending, or assisting veterans in obtaining marijuana.  While veterans may discuss marijuana use with VA providers, VA doctors cannot help their patients participate in a state medical marijuana program and veterans cannot obtain reimbursement funding through the VA when they seek medical marijuana from state programs.

The inability of the VA to prescribe or recommend marijuana to American veterans with PTSD denies former service members an opportunity to receive treatment that many veterans not only want, but which also has the potential to be safer than the VA’s history of doling out addictive prescription drugs such as opioids, antidepressants, and anti-anxiety pills.  PTSD is a serious disease that is relatively common among combat veterans — it causes varying symptoms such as flashbacks, nightmares, severe anxiety, and uncontrollable thought about a triggering event.

The medical research in this arena has reached mixed findings.  While some researchers have found that the use of medical marijuana by veterans with PTSD has positive results, other studies suggest that marijuana use by those with PTSD may actually make symptoms worse.  There simply has not been enough controlled studies to conclusively state whether marijuana is beneficial for those with PTSD.  Nonetheless, there is plenty of anecdotal evidence by veterans suggesting that their use of marijuana has improved, or in some cases eliminated, symptoms associated with their PTSD.  Fortunately, the first clinical trial of marijuana for American veterans with PTSD is currently underway in Colorado.  My presentation will suggest that we need more controlled clinical trials such as this to further identify whether marijuana could (or should) truly be used as a remedy for veterans with PTSD.

* Medical journal article, "Post-Traumatic Stress Disorder" (discussing what PTSD is and various treatment options, including cannabis).

* Medical journal article, "Use and effects of cannabinoids in military veterans with posttraumatic stress disorder"(reviewing several studies and noting that while there is a need for more randomized and controlled studies, some PTSD patients report benefits in terms of reduced anxiety and insomnia and improved coping ability).

* Medical journal article, "Posttraumatic Stress Disorder and Cannabis Use Characteristics among Military Veterans with Cannabis Dependence" (exploring the negative effects of treating PTSD with marijuana and finding that individuals with PTSD may have a particularly difficult experience when attempting to quit marijuana).

* Medical journal article, "Marijuana and other cannabinoids as a treatment for posttraumatic stress disorder: A literature review" (explaining that conclusions cannot yet be drawn about the therapeutic effects of marijuana and related cannabinoids for PTSD; suggesting that rapidly changing legal landscape will permit promising clinical research).

* Medical journal article, "A review of medical marijuana for the treatment of posttraumatic stress disorder: Real symptom re-leaf or just high hopes?" (finding some positive data for use of marijuana for PTSD but also noting conflicting findings and limits of studies conducted thus far).

* Report on study, "Marijuana for Symptoms of PTSD in U.S. Veterans" (first clinical trial of marijuana for PTSD in American veterans underway).

* Recent Weedmaps article, "Marijuana Study Findings Could Hold Promise for Veterans With PTSD" (noting that MAPS study mentioned above could pave the way toward an FDA-approved prescription medicine; anecdotal evidence of veteran using black market rather than expensive medical marijuana program in CA)

March 25, 2019 in Federal Marijuana Laws, Policies and Practices, Medical community perspectives, Medical Marijuana Commentary and Debate, Medical Marijuana Data and Research, Medical Marijuana State Laws and Reforms, Who decides | Permalink | Comments (0)

Tuesday, March 19, 2019

"The contribution of cannabis use to variation in the incidence of psychotic disorder across Europe (EU-GEI): a multicentre case-control study"

The title of this post is the title of this important new study appearing in The Lancet Psychiatry.  Here is its summary:

Background

Cannabis use is associated with increased risk of later psychotic disorder but whether it affects incidence of the disorder remains unclear.  We aimed to identify patterns of cannabis use with the strongest effect on odds of psychotic disorder across Europe and explore whether differences in such patterns contribute to variations in the incidence rates of psychotic disorder.

Methods

We included patients aged 18–64 years who presented to psychiatric services in 11 sites across Europe and Brazil with first-episode psychosis and recruited controls representative of the local populations.  We applied adjusted logistic regression models to the data to estimate which patterns of cannabis use carried the highest odds for psychotic disorder.  Using Europe-wide and national data on the expected concentration of Δ9-tetrahydrocannabinol (THC) in the different types of cannabis available across the sites, we divided the types of cannabis used by participants into two categories: low potency (THC <10%) and high potency (THC ≥10%). Assuming causality, we calculated the population attributable fractions (PAFs) for the patterns of cannabis use associated with the highest odds of psychosis and the correlation between such patterns and the incidence rates for psychotic disorder across the study sites.

Findings

Between May 1, 2010, and April 1, 2015, we obtained data from 901 patients with first-episode psychosis across 11 sites and 1237 population controls from those same sites.  Daily cannabis use was associated with increased odds of psychotic disorder compared with never users (adjusted odds ratio [OR] 3·2, 95% CI 2·2–4·1), increasing to nearly five-times increased odds for daily use of high-potency types of cannabis (4·8, 2·5–6·3).  The PAFs calculated indicated that if high-potency cannabis were no longer available, 12·2% (95% CI 3·0–16·1) of cases of first-episode psychosis could be prevented across the 11 sites, rising to 30·3% (15·2–40·0) in London and 50·3% (27·4–66·0) in Amsterdam.  The adjusted incident rates for psychotic disorder were positively correlated with the prevalence in controls across the 11 sites of use of high-potency cannabis (r = 0·7; p=0·0286) and daily use (r = 0·8; p=0·0109).

Interpretation

Differences in frequency of daily cannabis use and in use of high-potency cannabis contributed to the striking variation in the incidence of psychotic disorder across the 11 studied sites. Given the increasing availability of high-potency cannabis, this has important implications for public health.

March 19, 2019 in Medical community perspectives, Recreational Marijuana Data and Research | Permalink | Comments (0)

Tuesday, February 26, 2019

Two interesting new articles about the early operation of Ohio's medical marijuana program

OHIO-HERBAL-CLINIC-DOCTORS-OFFICE-OHIO-MEDICAL-MARIJUANA-CARD--300x300Two Ohio papers had two interesting new article about early developments in the operation of Ohio's still-new medical marijuana program.  Here are headlines, links and excerpts:

From the Akron Beacon Journal, "Ohio medical marijuana recommendations coming from clinics, not family doctors"

If you know someone who has received a recommendation to use medical marijuana, odds are the recommendation didn’t come from a family doctor or primary-care physician. The vast majority of recommendations in Ohio come from clinics that employ doctors solely to evaluate patients for medical marijuana, say people familiar with the industry....

“Marijuana-specific clinics fill a huge need,” said Dr. Joel Simmons, who runs the Ohio Herbal Clinic, a Near East Side cannabis clinic. While the clinics, many of which have out-of-state owners, have some critics, patient advocates say primary-care doctors are the ideal source for marijuana recommendations.

Those doctors better understand a patient’s needs and medical history, said Mary Jane Borden, co-founder of the Ohio Rights Group, which advocates for users of medicinal cannabis. When Ohio lawmakers wrote the state’s medical-marijuana law, they hoped that family physicians would be writing most recommendations, Borden said....

Clinics charge between $125 and $200 for an evaluation, which insurance won’t cover.  Because the clinics don’t negotiate with insurance companies, they clinics can charge whatever they want, said Emilie Ramach, founder and CEO of Compassionate Alternatives, a Columbus-based nonprofit agency that helps patients pay for medicinal cannabis.  Several clinic doctors, including Simmons, said they do their best to keep their prices reasonable.

From the Columbus Dispatch, "High prices keep many Ohioans out of legal cannabis market"

As Ohio’s medical marijuana industry finally takes off, some patients and advocates are griping about costs that put it out of reach for many people.  A steep price tag stems partly from the lack of competition, as Ohio only has seven dispensaries spread throughout the state, mostly in rural areas, experts said.  Costs are expected to drop as more dispensaries open and the industry finds its footing.

In the meantime, patients openly acknowledge buying the drug on the black market while they wait for prices to come down.  And without insurance to cover the expense, some worry that low-income people might never be able to afford medical cannabis....

Several local patients said using marijuana has improved their quality of life, but they must stretch their budgets to pay for it or buy it on the street.  “I’m not using as much as I probably need to be using,” said Mary Alleger, 31, of Reynoldsburg, who said she uses cannabis to treat post-traumatic stress disorder (PTSD) and ongoing pain from a botched medical procedure.

Katherin Cottrill, 33, of Newark, has worked with the patient advocacy organization Ohio Rights Group to acquire a medical marijuana card, but said current costs keep her from even getting started.  “I would have to pay $200 to $250 (just to get a recommendation),” Cottrill said.  “And then I have to drive to a dispensary and pay $50. It’s unreasonable for me to even try.”...

Just under 3 grams of medical marijuana costs about $50. Cannabis clinics charge between $125 and $200, and the state charges $50 in fees.  Marijuana is cheaper on the street, patients said.

“On the black market you can buy an ounce for $200,” said Robert Doyle, 61, of Newark, who has a medical marijuana card but still buys the drug on the street due to the cost.  There are about 28 grams in an ounce.  Doyle said he’s visited dispensaries in Michigan with prices comparable to the black market, making him confident that Ohio’s costs will eventually fall....

But even if prices drop, clinic costs and fees will remain a barrier for some, Cottrill said.  “What about low-income people who are desperately seeking medication?” she said. “They can’t even afford to pay $50 to get their card registered.”

February 26, 2019 in Business laws and regulatory issues, Medical community perspectives, Medical Marijuana Commentary and Debate, Medical Marijuana Data and Research, Medical Marijuana State Laws and Reforms, Who decides | Permalink | Comments (1)

Wednesday, February 13, 2019

"Association of Cannabis Use in Adolescence and Risk of Depression, Anxiety, and Suicidality in Young Adulthood: A Systematic Review and Meta-analysis"

Download (24)The title of this post is the title of this notable new article which just today is published online in JAMA Psychiatry.  Here is its front matter:

Key Points

Question

Is adolescent cannabis consumption associated with risk of depression, anxiety, and suicidality in young adulthood?

Findings

In this systematic review and meta-analysis of 11 studies and 23 317 individuals, adolescent cannabis consumption was associated with increased risk of developing depression and suicidal behavior later in life, even in the absence of a premorbid condition. There was no association with anxiety.

Meaning

Preadolescents and adolescents should avoid using cannabis as use is associated with a significant increased risk of developing depression or suicidality in young adulthood; these findings should inform public health policy and governments to apply preventive strategies to reduce the use of cannabis among youth.

Abstract

Importance

Cannabis is the most commonly used drug of abuse by adolescents in the world. While the impact of adolescent cannabis use on the development of psychosis has been investigated in depth, little is known about the impact of cannabis use on mood and suicidality in young adulthood.

Objective

To provide a summary estimate of the extent to which cannabis use during adolescence is associated with the risk of developing subsequent major depression, anxiety, and suicidal behavior.

Data Sources

Medline, Embase, CINAHL, PsycInfo, and Proquest Dissertations and Theses were searched from inception to January 2017.

Study Selection

Longitudinal and prospective studies, assessing cannabis use in adolescents younger than 18 years (at least 1 assessment point) and then ascertaining development of depression in young adulthood (age 18 to 32 years) were selected, and odds ratios (OR) adjusted for the presence of baseline depression and/or anxiety and/or suicidality were extracted.

Data Extraction and Synthesis

Study quality was assessed using the Research Triangle Institute item bank on risk of bias and precision of observational studies. Two reviewers conducted all review stages independently. Selected data were pooled using random-effects meta-analysis.

Main Outcomes and Measures

The studies assessing cannabis use and depression at different points from adolescence to young adulthood and reporting the corresponding OR were included. In the studies selected, depression was diagnosed according to the third or fourth editions of Diagnostic and Statistical Manual of Mental Disorders or by using scales with predetermined cutoff points.

Results

After screening 3142 articles, 269 articles were selected for full-text review, 35 were selected for further review, and 11 studies comprising 23 317 individuals were included in the quantitative analysis. The OR of developing depression for cannabis users in young adulthood compared with nonusers was 1.37 (95% CI, 1.16-1.62; I2 = 0%). The pooled OR for anxiety was not statistically significant: 1.18 (95% CI, 0.84-1.67; I2 = 42%). The pooled OR for suicidal ideation was 1.50 (95% CI, 1.11-2.03; I2 = 0%), and for suicidal attempt was 3.46 (95% CI, 1.53-7.84, I2 = 61.3%).

Conclusions and Relevance

Although individual-level risk remains moderate to low and results from this study should be confirmed in future adequately powered prospective studies, the high prevalence of adolescents consuming cannabis generates a large number of young people who could develop depression and suicidality attributable to cannabis. This is an important public health problem and concern, which should be properly addressed by health care policy.

February 13, 2019 in Medical community perspectives, Recreational Marijuana Data and Research | Permalink | Comments (5)

Monday, February 4, 2019

"Should Physicians Recommend Replacing Opioids With Cannabis?"

Download (3)The title of this post is the title of this short new "Viewpoint" piece authored by Keith Humphreys and Richard Saitz and published in the Journal of the American Medical Association.  I recommend the full piece, and here are excerpts:

Recent state regulations (eg, in New York, Illinois) allow medical cannabis as a substitute for opioids for chronic pain and for addiction.  Yet the evidence regarding safety, efficacy, and comparative effectiveness is at best equivocal for the former recommendation and strongly suggests the latter — substituting cannabis for opioid addiction treatments is potentially harmful.  Neither recommendation meets the standards of rigor desirable for medical treatment decisions.

Recent systematic reviews identified low-strength evidence that plant-based cannabis preparations alleviate neuropathic pain and insufficient evidence for other types of pain.  Studies tend to be of low methodological quality, involve small samples and short-follow-up periods, and do not address the most common causes of pain (eg, back pain).  This description of evidence for efficacy of cannabis for chronic pain is similar to how efficacy studies of opioids for chronic pain have been described (except that the volume of evidence is greater for opioids with 96 trials identified in a recent systematic review).

The evidence that cannabis is an efficacious treatment for opioid use disorder is even weaker.  To date, no prospective evidence, either from clinical trials or observational studies, has demonstrated any benefit of treating patients who have opioid addiction with cannabis.

Substituting cannabis for opioids is not the same as initiating opioid therapy.  There are no randomized clinical trials of substituting cannabis for opioids in patients taking or misusing opioids for treatment of pain, or in patients with opioid addiction treated with methadone or buprenorphine.  In addition to surveys of patients who use medical cannabis, the other types of studies prompting a move to cannabis to replace opioids are population-level reports stating that laws allowing medical cannabis use are followed by fewer opioid overdose deaths than expected.  The methodological concern with such studies is that correlation is not causation.  Many factors other than cannabis use may affect opioid overdose deaths, such as prescribing guidelines, opioid rescheduling, Good Samaritan laws, incarceration practices, and availability of evidence-based opioid use disorder treatment and naloxone....

For opioid use disorder, there is concern that the New York State Health Commissioner has defined opioid addiction to include people being treated with US Food and Drug Administration – approved, efficacious, opioid agonist medications, as a qualifying condition for medical cannabis.  Methadone and buprenorphine treatment reduces illicit opioid use, blood-borne disease transmission, criminal activity, adverse birth outcomes, and mortality.  Discontinuing such medications increases the risk of return to illicit opioid use, overdose, and death.  The suggestion that patients should self-substitute a drug (ie, cannabis) that has not been subjected to a single clinical trial for opioid addiction is irresponsible and should be reconsidered....

Cannabis and cannabis-derived medications merit further research, and such scientific work will likely yield useful results.  This does not mean that medical cannabis recommendations should be made without the evidence base demanded for other treatments. Evidence-based therapies are available.  For chronic pain, there are numerous alternatives to opioids aside from cannabis.  Nonopioid medications appear to have similar efficacy, and behavioral, voluntary, slow-tapering interventions can improve function and well-being while reducing pain.

For the opioid addiction crisis, clearly efficacious medications such as methadone and buprenorphine are underprescribed.  Without convincing evidence of efficacy of cannabis for this indication, it would be irresponsible for medicine to exacerbate this problem by encouraging patients with opioid addiction to stop taking these medications and to rely instead on unproven cannabis treatment.

February 4, 2019 in Medical community perspectives, Medical Marijuana Commentary and Debate, Medical Marijuana State Laws and Reforms, Who decides | Permalink | Comments (0)

Sunday, January 20, 2019

"If Weed Is Medicine, So Is Budweiser: Legalize marijuana, but don’t pretend it’s therapeutic."

Bach-peter_1The title of this post is the headline of this provocative Wall Street Journal commentary authored by Peter Bach, "a pulmonary physician at Memorial Sloan Kettering Cancer Center in New York [who] directs the Center for Health Policy and Outcomes."  Here are excerpts:

Ten states and the District of Columbia have legalized recreational marijuana use, and another eight look likely to do so in 2019.  I favor the move but am troubled by the gateway to it: All these jurisdictions first passed laws permitting the use of “medical” marijuana.  We should set the record straight, lest young people (and old ones) think marijuana is good for you because it is wrongly labeled a medication.

Actual medicines have research behind them, enumerating their benefits, characterizing their harms, and ensuring the former supersedes the latter.  Marijuana doesn’t.  It’s a toxin, not a medicine.  It impairs judgment and driving ability.  It increases the risk of psychosis and schizophrenia.  Smoking it damages the respiratory tract.  A 2017 report from the National Academy of Medicine called the evidence for these harms “substantial.”

Claims that marijuana relieves pain may be true.  But the clinical studies that have been done compare it with a placebo, not even a pain reliever like ibuprofen.  That’s not the type of rigorous evaluation we pursue for medications.  What’s more, every intoxicant would pass that sort of test because you don’t experience pain as acutely when you are high.  If weed is a pain reliever, so is Budweiser.

Some advocates say marijuana is better than opiates for pain.  Yet while opiates have risks, there are no studies comparing them to marijuana, and untested claims in medicine don’t get the benefit of the doubt.  Testing such a hypothesis often disproves it.

Decades ago, several studies suggested that marijuana might relieve nausea in chemotherapy patients.  But again most compared it with a placebo, while a few compared it with older nausea treatments not used today. None were very convincing. More important, no study has compared marijuana to today’s Neurokinin-1 antagonists. While such treatments are sometimes ineffective, that shortcoming doesn’t impart efficacy on marijuana either.

In writing medical-marijuana laws, state lawmakers and initiative authors have gone well beyond pain and nausea control, lauding the plant as an effective treatment for a long list of conditions, including hepatitis, Alzheimer’s and Parkinson’s.  Beyond the lack of data, what these conditions have in common isn’t biology, but modern medicine’s failure to treat them satisfactorily.  Heartbreaking as that is, marijuana isn’t the answer....

Marijuana belongs in the same category as alcohol and tobacco — harmful products that adults can choose to enjoy....  Decades passed before we took on smoking and drinking with education, labeling and other forms of regulation.  But it worked, and deaths from lung cancer, heart disease and alcohol-associated accidents are in sharp decline. We need this same approach with marijuana.  Acknowledging that it is not a medicine is a necessary first step.

I think it valuable and important to highlight ways in which many of the forms of the plant cannabis, at least right now, is not comparable to the kinds of medicines we access at a drug store.  But it is also important to highlight ways in which medical marijuana laws do not treat marijuana as comparable to other medicines. For starters, public and private health insurance systems general do not help cover the cost of marijuana used medicinally and there are all sorts of distinctive limits on the whos and hows of medical marijuana access.  In many ways, all modern medical marijuana laws are still just elaborate variations on the original law created by California in 1996, which simply created a limited exception to marijuana prohibition for those eager to try marijuana for various therapeutic purposes. Had marijuana never been criminalized, there would have been no need to seek exceptions from prohibition for medical uses (and, it bear recalling, there was much discussion and special laws around alcohol access for medical use during the Prohibition era).

January 20, 2019 in History of Alcohol Prohibition and Temperance Movements, History of Marijuana Laws in the United States, Medical community perspectives, Medical Marijuana Commentary and Debate, Who decides | Permalink | Comments (4)

Sunday, January 13, 2019

Maryland Medical Cannabis Commission report explores treatment of opioid use disorder by using medical cannabis

MJIN_Maryland-MMJ-Logo-Web-500x281The debate over the relationship between the opioid crisis and marijuana reforms is so very interesting and, of course, so very important.  Advocates for and against marijuana reform seem ever eager to leverage the opioid crisis (and everything else) to support their prior conclusions about the virtues or vices of marijuana reform.  Against this backdrop, I think  information from non-partisans is especially valuable, and thus I was pleased to see this notable new report from the Maryland Medical Cannabis Commission titled "Treatment of Opioid Use Disorder with Medical Cannabis."  I recommend the full report, which mostly just reports on the state of the law in many jurisdictions and research on these topics.  Here are excerpts:

Since 2016, at least nine states have considered legislation or regulations to allow medical cannabis as an opioid replacement therapy to help ease withdrawal symptoms and aid in relapse prevention....  In 2018, Pennsylvania, New Jersey, and New York became the first states to expressly allow medical cannabis for the treatment of OUD. Each state permits the use of medical cannabis to treat OUD, but with significant restrictions....

From 2016-2018, at least seven state legislatures considered bills that would expressly add OUD to the list of medical cannabis qualifying conditions.  Of these, the majority rejected the legislation seeking to add OUD to the list of qualifying conditions.  [T]hree states – Hawaii, Maine, and New Mexico – passed legislation authorizing the use of medical cannabis to treat OUD; however, the State’s Governor vetoed the legislation in each instance following significant pressure from health care providers, health care organizations, and addiction specialists....

Data suggest that cannabis legalization reduces prescription opioid use by serving as an alternative pain treatment. Medical cannabis laws may also have downstream policy effects on reducing opioid-related hospitalizations, overdose deaths, and traffic fatalities. The following section examines existing literature on the association between medical cannabis and opioid use, including as a treatment for opioid use disorder....

[But] a study was published in the “To the Editor” section of JAMA Internal Medicine in September 2018, which found that the opioid-related overdose death rate was accelerating in states where medical and/or adult use cannabis laws had been implemented. Moreover, the death rate surpassed that of nonlegalizing states. The study reviewed opioid-related overdose death data from 2010 to 2016, and determined that the age-adjusted death rate was higher in states with cannabis legalization and that the age-adjusted death rate was increasing at a faster rate than in non-legalizing states. While several researchers have challenged the methodology of this study – including the inaccurate assessment of states that have legalized medical and adultuse cannabis – the results call attention to the need for further investigation of the association between cannabis legalization and opioid-related overdose deaths....

In December 2018, the Commission received two petitions requesting the addition of OUD to the list of medical cannabis qualifying conditions. If the Commission determines that either or both of these petitions are “facially substantial” then it must conduct a public hearing within the next 12 months to evaluate whether the medical condition or disease should be included in the list of qualifying conditions.  The Commission’s Research Committee, which includes two physicians, a scientist, addiction specialist, and horticulturist, is currently evaluating the petitions to determine whether they are facially substantial and require a public hearing. The Commission will provide the General Assembly with updates on the status of the OUD petitions, including information on any public hearings to consider adding OUD as a qualifying medical condition.

January 13, 2019 in Medical community perspectives, Medical Marijuana Commentary and Debate, Medical Marijuana Data and Research, Medical Marijuana State Laws and Reforms, Who decides | Permalink | Comments (0)

Saturday, January 12, 2019

"Marijuana needs warning labels like tobacco for associated mental, physical health risks"

Download (3)The title of this post is the headline of this recent commentary in USA Today authored by DJ Jaffe, who is the executive director of Mental Illness Policy Org.  Here is an excerpt:

Before legislators legalize marijuana, they should require bold and direct warning labels to be placed on the packaging as is done with tobacco products. If the states fail to act, then the Food and Drug Administration should step in and require it.

In early 2017, after exhaustive review, the National Academies of Sciences, Engineering, and Medicine found that there are significant health risks associated with using cannabis and cannabinoids. Yet none of the 33 states that have legalized medical marijuana, or the 10 states that have legalized recreational use, gives adequate warnings of those risks.

The situation is similar to when cigarettes first became extensively marketed. The health risks were known but not disclosed, leading to disease and lives being lost. In addition to appearing on the packaging, the warning labels should be displayed prominently wherever the product is sold, in advertising and in mandated public service announcements funded by the marijuana industry.

The academies, founded by Congress, comprise the country’s leading researchers. They have become the nation’s most reputable arbiters of the science that should guide policy. The findings of the report, "The Health Effects of Cannabis and Cannabinoids," were particularly disturbing for people prone to mental illness and those who have a mental illness.

The report found either substantial or moderate evidence of an association between cannabis use and the development of schizophrenia or other psychoses; increased symptoms of mania and hypomania in individuals diagnosed with bipolar disorders; increased risk for the development of depressive disorders; and increased incidence of suicidal ideation, attempts and completions.

Schizophrenia and bipolar disorders are two of the most devastating neurobiological disorders and the ones that are often associated with homelessness and incarceration. If there is an association with using legalized marijuana, shouldn’t the public be warned?...

Washington and Colorado were the first states to legalize recreational marijuana. While both warn pregnant mothers not to use it, the only other significant warning on the packaging is that there “may be health risks,” a watered-down mealy mouthed warning that fails to give consumers the concrete information they need to avoid danger.

While the National Academies found "association," association is not the same as causality. Perhaps the increased risk of schizophrenia developing is because those who are prone to schizophrenia also are prone to use these products.

But until we know the chicken-or-egg answer, we should not follow the example of the tobacco regulation where the product was allowed to be marketed unencumbered by warnings, leading to more than 480,000 deaths a year, and subsequently the spending of millions of dollars re-educating consumers who had been misled in the first place.

January 12, 2019 in Business laws and regulatory issues, Medical community perspectives, Recreational Marijuana Commentary and Debate | Permalink | Comments (0)

Tuesday, January 8, 2019

Malcolm Gladwell rightly highlights how much we do not know about marijuana (but still ignores what we know about prohibition)

Gladwell-malcolmMalcolm Gladwell has this new extended essay in The New Yorker asking "Is Marijuana as Safe as We Think?".  The piece is somewhat focused on the forthcoming book by Alex Berenson (whose recent commentaries I have covered here and here), but it is most effective when it highlights that research on the public health consequences of marijuana remains incomplete and inconclusive.  Here is how the piece starts:

A few years ago, the National Academy of Medicine convened a panel of sixteen leading medical experts to analyze the scientific literature on cannabis. The report they prepared, which came out in January of 2017, runs to four hundred and sixty-eight pages. It contains no bombshells or surprises, which perhaps explains why it went largely unnoticed. It simply stated, over and over again, that a drug North Americans have become enthusiastic about remains a mystery.

For example, smoking pot is widely supposed to diminish the nausea associated with chemotherapy. But, the panel pointed out, “there are no good-quality randomized trials investigating this option.” We have evidence for marijuana as a treatment for pain, but “very little is known about the efficacy, dose, routes of administration, or side effects of commonly used and commercially available cannabis products in the United States.” The caveats continue. Is it good for epilepsy? “Insufficient evidence.” Tourette’s syndrome? Limited evidence. A.L.S., Huntington’s, and Parkinson’s? Insufficient evidence. Irritable-bowel syndrome? Insufficient evidence. Dementia and glaucoma? Probably not. Anxiety? Maybe. Depression? Probably not.

Then come Chapters 5 through 13, the heart of the report, which concern marijuana’s potential risks. The haze of uncertainty continues. Does the use of cannabis increase the likelihood of fatal car accidents? Yes. By how much? Unclear. Does it affect motivation and cognition? Hard to say, but probably. Does it affect employment prospects? Probably. Will it impair academic achievement? Limited evidence. This goes on for pages.

We need proper studies, the panel concluded, on the health effects of cannabis on children and teen-agers and pregnant women and breast-feeding mothers and “older populations” and “heavy cannabis users”; in other words, on everyone except the college student who smokes a joint once a month.

Gladwell later provides some context for how we should approach modern marijuana reform in light of all this uncertainty:

Drug policy is always clearest at the fringes. Illegal opioids are at one end.  They are dangerous.  Manufacturers and distributors belong in prison, and users belong in drug-treatment programs.  The cannabis industry would have us believe that its product, like coffee, belongs at the other end of the continuum. “Flow Kana partners with independent multi-generational farmers who cultivate under full sun, sustainably, and in small batches,” the promotional literature for one California cannabis brand reads.  “Using only organic methods, these stewards of the land have spent their lives balancing a unique and harmonious relationship between the farm, the genetics and the terroir.”   But cannabis is not coffee.  It’s somewhere in the middle.   The experience of most users is relatively benign and predictable; the experience of a few, at the margins, is not.  Products or behaviors that have that kind of muddled risk profile are confusing, because it is very difficult for those in the benign middle to appreciate the experiences of those at the statistical tails. Low-frequency risks also take longer and are far harder to quantify, and the lesson of “Tell Your Children” and the National Academy report is that we aren’t yet in a position to do so.  For the moment, cannabis probably belongs in the category of substances that society permits but simultaneously discourages.  Cigarettes are heavily taxed, and smoking is prohibited in most workplaces and public spaces.  Alcohol can’t be sold without a license and is kept out of the hands of children.  Prescription drugs have rules about dosages, labels that describe their risks, and policies that govern their availability. The advice that seasoned potheads sometimes give new users — “start low and go slow” — is probably good advice for society as a whole, at least until we better understand what we are dealing with.

I am not inclined to dispute much of what Gladwell has to say in this piece especially when he stresses uncertainty, but I am again eager to highlight what he ignores about the certain harms of prohibition. Notably, we still send a whole lot of drug users to prison rather than to treatment programs because of the "drug war" approach to criminalizing drug prohibitions, and we still arrest a whole lot of marijuana users. Moreover and even more importantly, the certain harms of marijuana prohibition are borne disproportionately by people of color and the poor.

I am supportive of a "start low and go slow” approach to the commercialization of marijuana based on all the uncertainty that Gladwell is eager to stress. But given the certain harms of prohibition and who is disproportionately subject to them, I do not think we can end the criminalization of marijuana soon enough.

January 8, 2019 in Medical community perspectives, Recreational Marijuana Commentary and Debate, Recreational Marijuana Data and Research, Who decides | Permalink | Comments (0)

Tuesday, January 1, 2019

Two deep dives into health research and social justice in modern age of marijuana reform

NBC News has two new lengthy articles exploring the state of marijuana research and debate over social justice in this era of marijuana reform.   Both pieces are worthwhile reads, and here are links to the pieces with extended headlines and a brief excerpt:

"The year in pot: States embrace legalization, but questions persist; Marijuana, the most widely used illegal drug in the U.S., is winning approval state by state and impressing investors. But researchers still caution against its use."

The wave of legalization is taking place as the latest polls show that nearly two-thirds of Americans endorse it, double the rate in 2000. Investors are noticing too, pouring an estimated $10 billion into the industry in North America this year.

Still, medical researchers continue to caution against its use because little is known about its effects on health. Here is a review of what we’ve learned about marijuana and marijuana-based products in 2018.

"Legal marijuana made big promises on racial equity — and fell short; 'Time is really up on selling your business dream as a social justice movement,' said the president of the Minority Cannabis Business Association."

While marijuana arrests have declined and tax revenue has begun to flow in most states that have legalized pot, the gains have accrued most heavily to white residents, even though black Americans paid the drug war’s biggest costs, according to a statistical analysis conducted by the Drug Policy Alliance, a nonprofit group that advocates drug policy reform.

The results in Colorado, the District of Columbia and the nine other states where recreational marijuana became legal from 2012 to 2018 have left some lawmakers and even marijuana legalization advocates skeptical of broad social-justice claims. For that reason, lawmakers in New Jersey and New York — two of the three states expected to legalize marijuana in 2019 — are now pushing for detailed criminal justice and business equity measures as part of any legalization package....

The efforts in New Jersey and New York come as the inequities in other states have grown clearer. In Colorado, the Drug Policy Alliance found, the number of black juveniles arrested on marijuana charges grew after legalization. In 2016, a Colorado Department of Public Safety analysis found that black people living in that state remained three times more likely than white people to be arrested for selling or possessing marijuana. In Washington state, an ACLU analysis found that in 2014, the first year in which marijuana became available in legal retail stores, a black adult remained three times more likely to face low-level marijuana charges than a white adult.

January 1, 2019 in Criminal justice developments and reforms, Medical community perspectives, Medical Marijuana Commentary and Debate, Race, Gender and Class Issues, Recreational Marijuana Commentary and Debate | Permalink | Comments (0)

Friday, December 28, 2018

"Alcohol Use and Risk of Related Problems Among Cannabis Users Is Lower Among Those With Medical Cannabis Recommendations, Though Not Due To Health"

DownloadThe title of this post is the headline of this encouraging article recently published in the Journal of Studies on Alcohol and Drugs authored by Meenakshi Subbaraman and William Kerr.  Here is its abstract:

Objective:

A small body of work has started developing cannabis use “typologies” for use in treatment and prevention. Two potentially relevant dimensions for classifying cannabis use typologies are medical versus recreational cannabis use and the co-use of cannabis and alcohol. Here we compare alcohol use and related problems between cannabis users with and without medical cannabis recommendations.

Method:

Data come from a larger general population study in Washington State conducted between January 2014 and October 2016.  All participants in the analytic sample (n = 991) reported using both alcohol and cannabis in the past 12 months.  The primary exposure was having a medical recommendation for cannabis.  Outcomes were past-30-day drinking (drinks/day, frequency of 5+ drinks, and maximum number of drinks in a day) and past-12-month Alcohol Use Disorders Identification Test (AUDIT) scores.

Results:

Compared with those without medical cannabis recommendations, cannabis users with medical cannabis recommendations had 0.59 times fewer drinks/day, 0.44 times fewer occasions drinking 5+, and 0.78 times the average maximum number of drinks in one day (all ps < .05).  Those with a recommendation also had 0.87 times lower AUDIT total scores (p < .05) and 0.57 times lower AUDIT problem scores (p < .01).

Conclusions:

Cannabis users with medical cannabis recommendations drink less and have fewer alcohol-related problems than those without recommendations, even after adjusting for health status. Future studies should examine non-health reasons regarding how medical and non-medical users use cannabis differently.

December 28, 2018 in Medical community perspectives, Medical Marijuana Data and Research | Permalink | Comments (0)

Tuesday, July 3, 2018

Big new Australian study throws cold water on marijuana as an effective pain reliever

Download (18)The huge 2017 National Academies of Sciences report titled "The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research" came to this encouraging conclusion in Chapter 4 of the report concerning the medicinal potential of marijuana: "There is substantial evidence that cannabis is an effective treatment for chronic pain in adults."

A big new study out of Australia, however, now throws some cold water on anyone getting to hot about marijuana's potential as an effective pain reliever. This Business Insider Australia article reports on the study under the headline "A 4-year Australian study of 1500 people finds no evidence that cannabis helps to treat pain." Here are excerpts:

A long term study by the University of NSW — one of the world’s longest in-depth community studies on pharmaceutical opioids and non-cancer pain — has found little evidence to support the use of cannabis in the treatment of chronic pain.

The four-year study of more than 1,500 Australians prescribed opioids for non-cancer pain suggest that there is a need for caution in using medicinal cannabis. Those in the study who used cannabis, and there were many among those with chronic non-cancer pain who had been prescribed opioids, actually had greater pain, anxiety and were coping less....

“Chronic non-cancer pain is a complex problem,” says Dr Gabrielle Campbell at the University of NSW, the lead author in the latest study. “For most people, there is unlikely to be a single effective treatment. In our study of people living with chronic non-cancer pain who were prescribed pharmaceutical opioids, despite reporting perceived benefits from cannabis use, we found no strong evidence that cannabis use reduced participants’ pain or opioid use over time.”

The Pain and Opioids IN Treatment (POINT) study, published today in the journal Lancet Public Health, looked at the effect of cannabis on pain, on the extent to which this interfered with everyday life, and on prescribed opioid use.

In the study, funded by the National Health and Medical Research Council and led by the National Drug and Alcohol Research Centre at UNSW Sydney, participants were recruited through community pharmacies and completed comprehensive assessments of their pain, physical and mental health, medication and cannabis.

Participants had been in pain for a median of 10 years and taken prescribed opioids for for four years. There were very high rates of physical and mental health problems. At each assessment, participants who were using cannabis reported greater pain and anxiety, were coping less well with their pain, and reported that pain was interfering more in their life, compared to those not using cannabis.

There was no clear evidence that cannabis led to reduced pain severity or pain interference or led participants to reduce their opioid use or dose. However, the users thought otherwise. Those who used cannabis, despite the study finding no evidence, reported that cannabis was effective (mean score of 7 out of 10). One possibility is that cannabis improves sleep, which in turn improves well-being, say the researchers.

The researchers say double-blind randomised placebo-controlled clinical trials are needed to better understand the impact of cannabis.

The full study being reported on is titled "Effect of cannabis use in people with chronic non-cancer pain prescribed opioids: findings from a 4-year prospective cohort study," and it is available at this link.  Reading the abstract makes clearer that this study was entirely observational in that participants were acquiring and using marijuana on their own and reporting that use rather than being giving marijuana in a controlled setting.

Among other reactions, this new study reinforces my sense that we need a lot more studies to really get a handle on the possible value of marijuana to help address the "complex problem" of chronic pain.  I am also struck by the line I emphasized above that indicate that a significant majority of marijuana users in the study believed that they were helped by marijuana when the evidence suggested otherwise.  A real interesting philosophical issue arises, for the medical profession and for governments, if it turns out that marijuana does not really help many chronic pain problems, but many users think that it does and are eager to have access to the drug because others report that it provides them relief.

July 3, 2018 in Medical community perspectives, Medical Marijuana Data and Research | Permalink | Comments (0)

Tuesday, June 26, 2018

SCOTUS provides a good new First Amendment precedent for doctors interested in recommending marijuana

Supreme-court-marijuanaThe modern state medical marijuana laws owe part of their structure to critical lower federal court rulings about the First Amendment's protection of doctors who wish to discuss marijuana use with patients.  In the late 1990s after California voters passed the nation's first medical marijuana law, the federal government threatened physicians who recommended or prescribed a Schedule I drug with possible revocation of DEA registration and exclusion from Medicare and Medicaid reimbursements.   But this threat was thwarted through litigation which culminated in a ruling by the U.S. Court of Appeals for the Ninth Circuit holding that physicians’ First Amendment freedom of speech rights under the privileged doctor-patient relationship permitted them to issue medical marijuana recommendations.  The Ninth Circuit's ruling in Conant v. Walters, 309 F.3d 629 (9th Cir. 2002), has provided a key foundation for modern medical marijuana regimes, but the firmness of that foundation could be questioned because the US Supreme Court has never addressed this issue directly.

As of this morning, the Supreme Court still has not addressed this issue directly, but it has now ruled in National Institute of Family and Life Advocates v. Becerra, available here, that the First Amendment limits what states can tell doctors and other health professional to say or not say.  Here is part of a fascinating passage (which even mentions medical marijuana, with my emphasis added) extolling the importance of broad constitutional protections in this realm:

As with other kinds of speech, regulating the content of professionals’ speech “pose[s] the inherent risk that the Government seeks not to advance a legitimate regulatory goal, but to suppress unpopular ideas or information.” Turner Broadcasting, 512 U. S., at 641.  Take medicine, for example. “Doctors help patients make deeply personal decisions, and their candor is crucial.” Wollschlaeger v. Governor of Florida, 848 F.3d 1293, 1328 (CA11 2017) (en banc) (W. Pryor, J. concurring).  Throughout history, governments have “manipulat[ed] the content of doctor-patient discourse” to increase state power and suppress minorities:

“For example, during the Cultural Revolution, Chinese physicians were dispatched to the countryside to convince peasants to use contraception. In the 1930s, the Soviet government expedited completion of a construction project on the Siberian railroad by ordering doctors to both reject requests for medical leave from work and conceal this government order from their patients.  In Nazi Germany, the Third Reich systematically violated the separation between state ideology and medical discourse. German physicians were taught that they owed a higher duty to the ‘health of the Volk’ than to the health of individual patients.  Recently, Nicolae Ceausescu’s strategy to increase the Romanian birth rate included prohibitions against giving advice to patients about the use of birth control devices and disseminating information about the use of condoms as a means of preventing the transmission of AIDS.” Berg, Toward a First Amendment Theory of Doctor-Patient Discourse and the Right To Receive Unbiased Medical Advice, 74 B. U. L. Rev. 201, 201– 202 (1994) (footnotes omitted).

Further, when the government polices the content of professional speech, it can fail to “‘preserve an uninhibited marketplace of ideas in which truth will ultimately prevail.’” McCullen v. Coakley, 573 U. S. ___, ___–___ (2014) (slip op., at 8–9).  Professionals might have a host of good-faith disagreements, both with each other and with the government, on many topics in their respective fields.  Doctors and nurses might disagree about the ethics of assisted suicide or the benefits of medical marijuana; lawyers and marriage counselors might disagree about the prudence of prenuptial agreements or the wisdom of divorce; bankers and accountants might disagree about the amount of money that should be devoted to savings or the benefits of tax reform.  “[T]he best test of truth is the power of the thought to get itself accepted in the competition of the market,” Abrams v. United States, 250 U. S. 616, 630 (1919) (Holmes, J., dissenting), and the people lose when the government is the one deciding which ideas should prevail.

Given the modern politics of marijuana reform, I was not that worried that the Ninth Circuit's work in Conant v. Walters would be undermined anytime soon. But it would not be too hard to imagine Attorney General Jeff Sessions or other state or federal officials resistant to marijuana reform trying to heavily regulate how medical professionals can talk to patients about marijuana. This new SCOTUS precedent would seem to limit such efforts.

June 26, 2018 in Court Rulings, History of Marijuana Laws in the United States, Medical community perspectives, Medical Marijuana Commentary and Debate, Who decides | Permalink | Comments (0)

Monday, June 25, 2018

Formal FDA approval for Epidiolex means some part of the federal government finds some part of cannabis plant has "accepted medical use"

Download (1)This new CNN piece, headlined "FDA approves first cannabis-based drug," reports on the big news from the federal government concerning a very specific form of medical marijuana. Here are the details:

The US Food and Drug Administration approved a cannabis-based drug for the first time, the agency said Monday. Epidiolex was recommended for approval by an advisory committee in April, and the agency had until this week to make a decision.

The twice-daily oral solution is approved for use in patients 2 and older to treat two types of epileptic syndromes: Dravet syndrome, a rare genetic dysfunction of the brain that begins in the first year of life, and Lennox-Gastaut syndrome, a form of epilepsy with multiple types of seizures that begin in early childhood, usually between 3 and 5.

"This is an important medical advance," FDA Commissioner Dr. Scott Gottlieb said in a statement Monday. "Because of the adequate and well-controlled clinical studies that supported this approval, prescribers can have confidence in the drug's uniform strength and consistent delivery."

The drug is the "first pharmaceutical formulation of highly-purified, plant-based cannabidiol (CBD), a cannabinoid lacking the high associated with marijuana, and the first in a new category of anti-epileptic drugs," according to a statement Monday from GW Pharmaceuticals, the UK-based biopharmaceutical company that makes Epidiolex....

The FDA has approved synthetic versions of some cannabinoid chemicals found in the marijuana plant for other purposes, including cancer pain relief. Justin Gover, chief executive officer of GW Pharmaceuticals, described the approval in the statement as "a historic milestone." He added that the drug offers families "the first and only FDA-approved cannabidiol medicine to treat two severe, childhood-onset epilepsies."

"These patients deserve and will soon have access to a cannabinoid medicine that has been thoroughly studied in clinical trials, manufactured to assure quality and consistency, and available by prescription under a physician's care," Gover said. Epidiolex will become available in the fall, Gover told CNN.  He would not give any information on cost, saying only that it will be discussed with insurance companies and announced later....

It's an option for those patients who have not responded to other treatments to control seizures.  According to the Epilepsy Foundation, up to one-third of Americans who have epilepsy have found no therapies that will control their seizures. Shauna Garris, a pharmacist, pharmacy clinical specialist and adjunct assistant professor at the University of North Carolina's Eshelman School of Pharmacy, said the drug is effective and works somewhere between "fairly" and "very well." She has not used Epidiolex in her own clinical practice and was not involved in the development of the drug but said she's not sure it will live up to "all of the hype" that has surrounded it....

As part of the FDA's review of the medication, the potential for abuse was assessed and found to be low to negative, according to Gover. Still, this approval comes as the White House is said to be reconsidering federal prohibition of marijuana and as more and more states approve it for recreational and medicinal use. Gover said the approval signals "validation of the science of cannabinoid medication."

As the title of this post highlights, this news serves as still further proof of the misguided placement of marijuana as a Schedule I drug under the Controlled Substances Act defined as having "no currently accepted medical use in treatment in the United States." But, it should also be realize that this news serves as proof that the federal government, even without any reform to the CSA, can and will approve a cannabis-based medicine which has been "thoroughly studied in clinical trials [and] manufactured to assure quality and consistency."  Thus, the catch-22 comes from the fact that marijuana's placement on Schedule I precludes US-based companies from doing the types of clinical trials that the FDA demands.  (If we had a well-functioning federal government, marijuana surely would have been at least re-scheduled to Schedule II or III under the CSA many years ago.  But I digress....)

June 25, 2018 in Business laws and regulatory issues, Federal Marijuana Laws, Policies and Practices, History of Marijuana Laws in the United States, Medical community perspectives, Medical Marijuana Commentary and Debate, Who decides | Permalink | Comments (0)

Monday, June 4, 2018

Medical marijuana news nationwide, in states large and small, developing and debated

There are so many interesting developments, some small and some big, in medical marijuana states that I cannot come close to keeping track of it all.  Having seen a lot of notable stories in a lot of states in recent days, I figured it might be time to do a round-up of stories that caught my eye.  So, though this is not in any sense comprehensive, here goes in alphabetical order:

From Arkansas here, "Arkansas Supreme Court to hear dispute over medical marijuana rollout"

From Connecticut here, "With booming medical marijuana program, some fear shortages"

From Georgia here, "Georgia couple loses custody of son after giving him marijuana to treat seizures"

From Florida here, "As marijuana dispensaries open their doors, Florida registers 5,400 new users per week"

From Maryland here, "Overwhelmed computer system stalls medical marijuana sales over weekend in Maryland

From Ohio here, "Ohio announces 56 sites where medical marijuana will be sold"

From Oklahoma here, "Oklahoma's medical marijuana law would be unique"

From Utah here, "Unofficially, many Utah law enforcement groups are lining up to oppose the medical marijuana initiative"

June 4, 2018 in Medical community perspectives, Medical Marijuana Commentary and Debate, Medical Marijuana Data and Research, Medical Marijuana State Laws and Reforms | Permalink | Comments (1)

Sunday, May 27, 2018

"Could medical marijuana help fight opioid abuse? It’s complicated"

MarijuanavopioidsThe title of this post is the thoughtful headline of this article from Illinois thoughtfully discussing the issues surrounding the relationship between opioid use and marijuana access.  Here are excerpts:

Tom Utley says medical marijuana allowed him to reduce his use of prescription painkillers by 98 percent over the past year and a half. “It has given me control of my life,” said Utley, 42, a Mason County resident whose chronic pain after a car crash 27 years ago used to require him to swallow Vicodin and OxyContin pills four times a day.  Now he takes prescription opioids only a few times each month.

Utley, who works part time running a gymnastics tumbling program, has found relief in marijuana-infused topical lotions and patches, as well as smokable cannabis, from Springfield’s HCI Alternatives dispensary. Unlike prescription opioids, marijuana doesn’t come with the unwanted side-effects of constipation, cravings and cloudy thinking, he said....

Utley is among those who see expanded access to medical marijuana for people in pain as one solution for the nationwide epidemic of addiction to legal opioid painkillers and illegal opioids such as heroin and fentanyl.  There were about 2,000 fatal and 14,000 nonfatal opioid overdoses in Illinois last year. “I think it would be a way-better alternative,” Utley said of medical cannabis....

The Illinois General Assembly is considering a bill that could vastly expand the number of people qualifying for the state’s medical marijuana pilot program.  Senate Bill 336 would allow people who have been or could be prescribed opioids to apply for acceptance into the program.  The science surrounding the therapeutic benefits of marijuana is far from conclusive. But those shades of gray are missing from descriptions of both the benefits of cannabis from supporters of SB 336, and the drawbacks cited by opponents.

“Public policy is light years ahead of the science right now,” said Ziva Cooper, a research scientist who is associate professor of clinical neurobiology in psychiatry at Columbia University in New York. “There seems to be this nationwide experiment on the effects of cannabis that is happening in the absence of rigorous studies.”

SB 336 passed the Illinois Senate on a 44-6 vote April 26.  The bill is expected to receive a vote from the full House by the end of the week....  A spokeswoman for Gov. Bruce Rauner, a Republican, didn’t respond when asked the likelihood that Rauner would sign the bill into law if it reaches his desk.

Supporters of the legislation cite studies that have documented a correlation between a reduction in opioid-related fatalities and opioid prescriptions in states that allow the use of marijuana for medical or recreational purposes.  “The science is generally supportive of the concept,” said state Sen. Don Harmon, D-Oak Park, the bill’s chief Senate sponsor. “People don’t die from cannabis. I don’t feel like we’re doing much harm.”

But those studies, as well as numerous anecdotal reports from patients, don’t necessarily prove that expanding medical marijuana use leads to positive outcomes for the general population, Cooper said.  Results also aren’t conclusive when it comes to the negative implications of cannabis use reported in other legitimate but non-definitive studies, she said.  Those studies, publicized by Springfield-based Illinois Church Action on Alcohol and Addiction Problems, suggest marijuana is associated with an increased risk of prescription opioid misuse and addiction, and actually may contribute to the opioid epidemic....

Cooper said, “There is correlational evidence on both sides of the argument.” ...  The studies do make a compelling argument that more and more-rigorous follow-up studies are needed, she said while declining to comment on SB 336. “It’s just going to take time for us to do the studies that will yield the actual data that support some of these things we’re hearing about in the media,” she said.

Cooper was a member of a committee convened by the National Academies of Sciences, Engineering and Medicine that issued a report in January 2017 on the current state of evidence surrounding the health effects from cannabis and chemicals in cannabis known as cannabinoids.  The report said there is “conclusive” or “substantial” evidence that cannabis or cannabinoids are effective for the treatment of chronic pain in adults. “But there are a couple of caveats,” she said.  For example, she said, the report didn’t say there’s conclusive evidence that cannabis is more effective than opioids in helping patients deal with pain....

Data from the state indicate that 3 million Illinoisans obtained an opioid prescription in 2016, according to Chris Stone, chief executive officer of HCI Alternatives.  Even if just 10 percent of those patients sought temporary access to the state’s medical marijuana program under the provisions of SB 336, up to 300,000 people would join a program currently serving 36,800 people, he said....

Illinois, unlike most states with medical marijuana programs, doesn’t allow a general diagnosis of pain to qualify patients for the program, Cassidy said.  The Illinois Department of Public Health is appealing a Cook County judge’s January ruling ordering the department to add “intractable pain” to the list of qualifying conditions for medical marijuana.

IDPH director Dr. Nirav Shah has said there was a lack of “high-quality data” to justify adding pain to the list of more than 30 conditions, which include cancer, AIDS, spinal cord injury, seizures and fibromyalgia. SB 336 isn’t designed to add pain patients to the program for the rest of their lives. “This is really about folks who are looking at a six-month period of time of needing these medications or a three-month time period — for those folks who are very much at risk of addiction,” Cassidy said.

Some (of many) prior related posts:

May 27, 2018 in Medical community perspectives, Medical Marijuana Commentary and Debate | Permalink | Comments (0)

Monday, April 30, 2018

Lots of new medical marijuana coverage via CNN

Last night CNN aired the fourth installment of Chief Medical Correspondent Dr. Sanjay Gupta's programming about marijuana.  This Special Report was titled "Weed 4: Pot vs. Pills," and CNN has has a number of stories in recent days related to its work in this space.  Here are links to just some of its recent coverage:

April 30, 2018 in History of Marijuana Laws in the United States, Medical community perspectives, Medical Marijuana Commentary and Debate, Medical Marijuana Data and Research | Permalink | Comments (0)

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)