Marijuana Law, Policy & Reform

"The Impact of Medical Marijuana Laws and Dispensaries on Self-Reported Health"

The title of this post is the title of this notable new article authored by Elena Andreyeva and Benjamin Ukert published in the Forum for Health Economics & Policy. Here is its abstract:

Growing evidence suggests that medical marijuana laws have harm reduction effects across a variety of outcomes related to risky health behaviors.  This study investigates the impact of medical marijuana laws on self-reported health using data from the Behavioral Risk Factor Surveillance System from 1993 to 2013.  In our analyses we separately identify the effect of a medical marijuana law and the impact of subsequent active and legally protected dispensaries.

Our main results show surprisingly limited improvements in self-reported health after the legalization of medical marijuana and legally protected dispensaries.  Subsample analyses reveal strong improvements in health among non-white individuals, those reporting chronic pain, and those with a high school degree, driven predominately by whether or not the state had active and legally protected dispensaries.  We also complement the analysis by evaluating the impact on risky health behaviors and find that the aforementioned demographic groups experience large reductions in alcohol consumption after the implementation of a medical marijuana law.

"Cannabinoids for the treatment of mental disorders and symptoms of mental disorders: a systematic review and meta-analysis"

The title of this post is the title of this notable new article by multiple authors published in The Lancet Psychiatry. Here is its "Summary":

Background

Medicinal cannabinoids, including medicinal cannabis and pharmaceutical cannabinoids and their synthetic derivatives, such as tetrahydrocannabinol (THC) and cannabidiol (CBD), have been suggested to have a therapeutic role in certain mental disorders.  We analysed the available evidence to ascertain the effectiveness and safety of all types of medicinal cannabinoids in treating symptoms of various mental disorders.

Methods

For this systematic review and meta-analysis we searched MEDLINE, Embase, PsycINFO, the Cochrane Central Register of Controlled Clinical Trials, and the Cochrane Database of Systematic Reviews for studies published between Jan 1, 1980, and April 30, 2018.  We also searched for unpublished or ongoing studies on ClinicalTrials.gov, the EU Clinical Trials Register, and the Australian and New Zealand Clinical Trials Registry.  We considered all studies examining any type and formulation of a medicinal cannabinoid in adults (≥18 years) for treating depression, anxiety, attention-deficit hyperactivity disorder (ADHD), Tourette syndrome, post-traumatic stress disorder, or psychosis, either as the primary condition or secondary to other medical conditions.  We placed no restrictions on language, publication status, or study type (ie, both experimental and observational study designs were included). Primary outcomes were remission from and changes in symptoms of these mental disorders.  The safety of medicinal cannabinoids for these mental disorders was also examined. Evidence from randomised controlled trials was synthesised as odds ratios (ORs) for disorder remission, adverse events, and withdrawals and as standardised mean differences (SMDs) for change in symptoms, via random-effects meta-analyses.  The quality of the evidence was assessed with the Cochrane risk of bias tool and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.  This study is registered with PROSPERO (CRD42017059372, CRD42017059373, CRD42017059376, CRD42017064996, and CRD42018102977).

Findings

83 eligible studies (40 randomised controlled trials, n=3067) were included: 42 for depression (23 randomised controlled trials; n=2551), 31 for anxiety (17 randomised controlled trials; n=605), eight for Tourette syndrome (two randomised controlled trials; n=36), three for ADHD (one randomised controlled trial; n=30), 12 for post-traumatic stress disorder (one randomised controlled trial; n=10), and 11 for psychosis (six randomised controlled trials; n=281).  Pharmaceutical THC (with or without CBD) improved anxiety symptoms among individuals with other medical conditions (primarily chronic non-cancer pain and multiple sclerosis; SMD −0·25 [95% CI −0·49 to −0·01]; seven studies; n=252), although the evidence GRADE was very low.  Pharmaceutical THC (with or without CBD) worsened negative symptoms of psychosis in a single study (SMD 0·36 [95% CI 0·10 to 0·62]; n=24). Pharmaceutical THC (with or without CBD) did not significantly affect any other primary outcomes for the mental disorders examined but did increase the number of people who had adverse events (OR 1·99 [95% CI 1·20 to 3·29]; ten studies; n=1495) and withdrawals due to adverse events (2·78 [1·59 to 4·86]; 11 studies; n=1621) compared with placebo across all mental disorders examined.  Few randomised controlled trials examined the role of pharmaceutical CBD or medicinal cannabis.

Interpretation

There is scarce evidence to suggest that cannabinoids improve depressive disorders and symptoms, anxiety disorders, attention-deficit hyperactivity disorder, Tourette syndrome, post-traumatic stress disorder, or psychosis. There is very low quality evidence that pharmaceutical THC (with or without CBD) leads to a small improvement in symptoms of anxiety among individuals with other medical conditions.  There remains insufficient evidence to provide guidance on the use of cannabinoids for treating mental disorders within a regulatory framework.  Further high-quality studies directly examining the effect of cannabinoids on treating mental disorders are needed.

"Ohio's Medical Marijuana Control Program: Online Survey of Consumer Satisfaction"

The title of this post is the title of this new report authored by Nicholas Maxwell, who this summer served as a Research Fellow at Harm Reduction Ohio and who put together this report in conjunction with Ohio State's Drug Enforcement and Policy Center (which I help run).   The report will be one of a number of topics discussed at this DEPC event tonight, and here is its "summary and key findings":

An online survey of more than 600 Ohioans, most of whom reported being regular users of marijuana, revealed immense dissatisfaction with the Ohio medical marijuana system.  Consumers were surveyed on a range of topics, from their marijuana consumption habits to their experience with the Ohio MMCP.  The price of medical marijuana in Ohio was the primary driver of consumer dissatisfaction.  Contributing to this dissatisfaction was also reported inconvenience of registering for the program and traveling the sometimes-significant distance to the nearest dispensary.  The vast majority of respondents stated that they preferred to purchase marijuana from medical dispensaries, but reported that Ohio’s existing medical marijuana regime presented significant barriers that deterred them from doing so.

• 78% of 647 surveyed Ohioans reported a qualifying condition under the medical marijuana program.  Most respondents reporting a qualifying condition reported that they had chronic, severe, or intractable pain, which is consistent with the population of Ohio enrolled in its medical marijuana program.

• 81% of the 505 people who reported a qualifying condition also reported that they currently use marijuana.

• Only 45% of the 407 people who reported a qualifying condition and to be currently using marijuana have received a doctor’s recommendation under the MMCP.

• 67% of all 647 respondents reported being “very dissatisfied” or “somewhat dissatisfied” with the Ohio medical marijuana program, with only 16.7% of people reporting being somewhat or very satisfied.

• 87% of all 647 respondents indicated preference for purchasing marijuana from a legal dispensary if product was similarly priced to product available via the unregulated market.

• On average, people were willing to pay a 16.9% price premium to buy marijuana at legal dispensaries instead of the unregulated market.  At current levels, the premium stands at more than 100%.

"DEA Announces Steps Necessary to Improve Access to Marijuana Research"

The title of this post is the title of this notable new Department of Justice press release.  Here is its full text:

The Drug Enforcement Administration today announced that it is moving forward to facilitate and expand scientific and medical research for marijuana in the United States. The DEA is providing notice of pending applications from entities applying to be registered to manufacture marijuana for researchers. DEA anticipates that registering additional qualified marijuana growers will increase the variety of marijuana available for these purposes.

Over the last two years, the total number of individuals registered by DEA to conduct research with marijuana, marijuana extracts, derivatives and delta-9-tetrahydrocannabinol (THC) has increased by more than 40 percent from 384 in January 2017 to 542 in January 2019. Similarly, in the last two years, DEA has more than doubled the production quota for marijuana each year based on increased usage projections for federally approved research projects.

“I am pleased that DEA is moving forward with its review of applications for those who seek to grow marijuana legally to support research,” said Attorney General William P. Barr. “The Department of Justice will continue to work with our colleagues at the Department of Health and Human Services and across the Administration to improve research opportunities wherever we can.”

“DEA is making progress in the program to register additional marijuana growers for federally authorized research, and will work with other relevant federal agencies to expedite the necessary next steps,” said DEA Acting Administrator Uttam Dhillon. “We support additional research into marijuana and its components, and we believe registering more growers will result in researchers having access to a wider variety for study.”

This notice also announces that, as the result of a recent amendment to federal law, certain forms of cannabis no longer require DEA registration to grow or manufacture. The Agriculture Improvement Act of 2018, which was signed into law on Dec. 20, 2018, changed the definition of marijuana to exclude “hemp”—plant material that contains 0.3 percent or less delta-9 THC on a dry weight basis. Accordingly, hemp, including hemp plants and cannabidiol (CBD) preparations at or below the 0.3 percent delta-9 THC threshold, is not a controlled substance, and a DEA registration is not required to grow or research it.

Before making decisions on these pending applications, DEA intends to propose new regulations that will govern the marijuana growers program for scientific and medical research. The new rules will help ensure DEA can evaluate the applications under the applicable legal standard and conform the program to relevant laws. To ensure transparency and public participation, this process will provide applicants and the general public with an opportunity to comment on the regulations that should govern the program of growing marijuana for scientific and medical research.

"The Effects of Recreational Marijuana Legalization and Dispensing on Opioid Mortality"

The title of this post is the title of this notable new article recently published in the journal Economic Inquiry authored by Nathan Chan, Jesse Burkhardt and Matthew Flyr.  Here is its abstract:

This study documents how the changing legal status of marijuana has impacted mortality in the United States over the past two decades.  We use a difference‐in‐difference approach to estimate the effect of medical marijuana laws (MML) and recreational marijuana laws (RML) on fatalities from opioid overdoses, and we find that marijuana access induces sharp reductions in opioid mortality rates.  Our research corroborates prior findings on MMLs and offers the first causal estimates of RML impacts on opioid mortality to date, the latter of which is particularly important given that RMLs are far more expansive in scope and reach than MMLs.

In our preferred econometric specification, we estimate that RMLs reduce annual opioid mortality in the range of 20%–35%, with particularly pronounced effects for synthetic opioids.  In further analysis, we demonstrate how RML impacts vary among demographic groups, shedding light on the distributional consequences of these laws. Our findings are especially important and timely given the scale of the opioid crisis in the United States and simultaneously evolving attitudes and regulations on marijuana use.

"State Of The States Report: An Analysis Of Medical Cannabis Access In The United States"

The title of this post is the title of this huge new version of an annual report produced by Americans for Safe Access. Here is part of the introductory letter from Steph Sherer, the President and Founder of ASA, at the start of the 178-page report:

Each year, Americans for Safe Access (ASA) analyzes, summarizes, and critiques legislation and regulations as they become law and develops this report to assess how these programs are serving the needs of patients.  In 2014, when we first started writing this report, only 22 states were analyzed and graded.  Now, six years later, we are analyzing 47 states in over 50 categories surrounding Patient Rights and Civil Protection from Discrimination, Access to Medicine, Ease of Navigation, Functionality of the Program, and Consumer Safety and Provider Requirements.

Through this report, ASA also recommends how states can improve programs, and we take great pride in knowing that these recommendations are frequently followed and incorporated by regulators and policymakers.  While we are excited to see the number of states with medical cannabis programs increase, we know this patchwork of laws is not working to provide access to everyone who needs this medicine.  Patients can still not travel to other states with their medicine, and some states only offer protections that cover a small subset of patients using a certain type of medicine.  The types of medicine available, method of administration, purchase limits, training requirements for staff, labeling requirements, etc. are different depending on the state that you are lucky, or unlucky, enough to live in.

"Is Cannabis a Gateway Drug? Key Findings and Literature Review"

The title of this post is the title of this lengthy report published in November 2018 produced by the Federal Research Division of the Library of Congress in conjunction with the National Institute of Justice.  For some reason, I missed this notable report when it was first released and tripped across it just this past week.  Here are the three lead findings of the full report:

1. The existing statistical research and analysis show mixed results and do not clearly demonstrate scientific support for cannabis use leading to harder illicit drug use.  As a result, FRD has determined that no causal link between cannabis use and the use of other illicit drugs can be claimed at this time.

2. The current state of research on this topic is very limited and existing studies suffer from difficulties in gathering information and applying the findings to a larger population.

3. While many of the studies reviewed in this report did find statistically significant associations between cannabis use and one’s later use of other illicit drugs, there is not yet conclusive evidence to assert that cannabis is a gateway drug. Moreover, the practical significance of these findings was limited.

Notable new data run suggest marijuana reform not (yet?) resulting in increase in teen marijuana use

Earlier this week, the journal JAMA Pediatrics published this notable "Research Letter" titled "Association of Marijuana Laws With Teen Marijuana Use: New Estimates From the Youth Risk Behavior Surveys."  This AP article reports on its findings and why the research is garnering attention:

New research suggests legalizing recreational marijuana for U.S. adults in some states may have slightly reduced teens’ odds of using pot. One reason may be that it’s harder and costlier for teens to buy marijuana from licensed dispensaries than from dealers, said lead author Mark Anderson, a health economist at Montana State University.

The researchers analyzed national youth health and behavior surveys from 1993 through 2017 that included questions about marijuana use. Responses from 1.4 million high school students were included.

Thirty-three states have passed medical marijuana laws and 11 have legalized recreational use — generally for ages 21 and up, many during the study years. The researchers looked at overall changes nationwide, but not at individual states. There was no change linked with medical marijuana legislation but odds of teen use declined almost 10% after recreational marijuana laws were enacted....

Previous research has found no effect on teen use from medical marijuana laws, and conflicting results from recreational marijuana laws. The new results echo a study showing a decline in teen use after sales of recreational pot began in 2014 in Washington state. The results “should help to quell some concerns that use among teens will actually go up. This is an important piece when weighing the costs and benefits of legalization,” Anderson said.

But Linda Richter, director of policy research and analysis at the nonprofit Center on Addiction, questioned the new findings. The center is a drug use prevention and treatment advocacy group. “It sort of defies logic to argue that more liberal recreational marijuana laws somehow help to dissuade young people from using the drug,” Richter said.

Other studies have found that, in states where use is legal, fewer teens think it is risky or harmful than the national average, she said. And teens in those states still have access to marijuana. “There is plenty of research showing that the black market for marijuana is alive and well in states that have legalized recreational use,” Richter said.

As the title of this post suggest, I think it is still way too early to reach any clear conclusions about how marijuana reform laws are impacting marijuana use among any and all populations. I am glad there is a robust effort to keep a close eye on these teen use data, and lots of factors surely impact use patterns locally and nationally.  So this seems to me another bit of data in a story that we must keep watching for many years to come (along with teen use of alcohol and other drugs in a modern marijuana reform era).

"Use of Cannabis to Relieve Pain and Promote Sleep by Customers at an Adult Use Dispensary"

The title of this post is the title of this notable new research authored by Marcus Bachhuber, Julia Arnsten and Gwen Wurm and published in the Journal of Psychoactive Drugs.  Here is its abstract and concluding paragraph:

Medical cannabis patients consistently report using cannabis as a substitute for prescription medications; however, little is known about individuals accessing cannabis through adult-use markets.  A survey at two retail stores was conducted in Colorado, United States.  Between August 2016 and October 2016, store staff asked customers if they wanted to participate and, if so, provided an electronic survey link.  All customers reporting medical certification were excluded.  Of 1,000 adult-use only customer respondents, 65% reported taking cannabis to relieve pain and 74% reported taking cannabis to promote sleep. 

Among respondents taking cannabis for pain, 80% reported that it was very or extremely helpful, and most of those taking over-the-counter pain medications (82%) or opioid analgesics (88%) reported reducing or stopping use of those medications.  Among respondents taking cannabis for sleep, 84% found it very or extremely helpful, and most of those taking over-the-counter (87%) or prescription sleep aids (83%) reported reducing or stopping use of those medications.  De facto medical use of cannabis for symptom relief was common among adult-use dispensary customers and the majority reported that cannabis decreased their medication use.  Adult use cannabis laws may broaden access to cannabis for the purpose of symptom relief.....

In summary, we found that de facto medical cannabis use is common among adult use customers at a cannabis dispensary.  Both pain relief and sleep promotion are common reasons for cannabis use, and the majority of respondents who reported using cannabis for these reasons also reported decreasing or stopping their use of prescription or over-the-counter analgesics and sleep aids.  While adult-use laws are frequently called “recreational,” implying that cannabis obtained through the adult use system is only for pleasure or experience-seeking, our findings suggest that many customers use cannabis for symptom relief.

Two very different tales of state medical marijuana reform in Oklahoma and West Virginia

Way back in April 2017, as spotlighted in this post, West Virginia become first new medical marijuana state of the Trump era when Gov. Jim Justice signed a comprehensive medical marijuana bill into law.  But, as highlighted by this new Marijuana Business Daily article, headlined "West Virginia medical marijuana sales start delayed until 2021 or 2022," two years later the state is still nowhere near an operational medical marijuana program:

Allison Adler, director of communications for the West Virginia Department of Health, wrote in an email to MJBizDaily that the “primary cause” behind the projected two- to three-year delay is concern about the ability of MMJ companies to secure banking services. The banking issue was addressed in recent legislation. The state treasurer, Adler noted, recently issued a request for proposals from financial institutions interested in providing banking services to the industry. However, the proposals will “require time to evaluate and implement.”

Adler continued that “it is important to note that after a solution to the current banking issue is found, it will take time for multiple stages of the medical cannabis permitting process to be implemented.” The whole process, she added, also requires program staffing and development, rules implementation and registration of medical providers and patients.

Meanwhile, a thousand miles away, a different route to medical marijuana reform has helped produce a very difference experience in Oklahoma. One year ago, as noted in this post, Oklahoma voters passed a medical marijuana initiative’s passage by the wide margin of 57 percent to 43 percent.  And this recent article, headlined "One year after SQ 788 vote, Oklahoma near No. 1 for patients among medical marijuana states," details how quickly the state has become record setting:

When Oklahomans voted one year ago in favor of State Question 788, officials thought about 80,000 patients, or about 2% of the state’s estimated population, would register in the first year of a legal medical marijuana program.

As of June 24, the Oklahoma Medical Marijuana Authority has already registered more than 3.5% of the population as patients, with little sign of applications slowing. That participation rate puts Oklahoma near No. 1 among the 33 states that have some form of medical cannabis legislation in place as of May.

Comparatively low financial barriers, combined with a lack of restrictions on qualifying conditions, brought patients out in droves to apply for licenses, OMMA Executive Director Adrienne Rollins said last week.

Oklahoma’s medical cannabis law, unlike the laws of most other states, does not have a list of qualifying medical conditions patients must prove to enroll. “I think everyone took the language of the state question to heart by not adding medical condition qualifiers,” Rollins said of lawmakers who worked the past legislative session to expand Oklahoma’s medical marijuana regulations....

U.S. Census data indicates Oklahoma has a projected 3.943 million residents as of 2018. With nearly 140,000 patients on record as of June 17, Oklahoma’s registration rate is about 35 per 1,000 people.

Maine, the closest comparison, removed qualifying conditions from its law last year after medical marijuana became legal in 1999 and does not require patients to register with the state. The Office of Marijuana Policy in Maine released statistics showing a printed patient certification card rate of about 34.3 per 1,000 residents in 2018.

California, a state with both medical and recreational cannabis laws, also does not require patients to obtain an identification card to take advantage of its medical law, Proposition 215, which took effect in 1996. However, organizations such as the Marijuana Policy Project estimate California has a registration rate of about 31 patients per 1,000 residents.

“The numbers are already at least roughly tied with the highest participation rate in the country,” said Karen O’Keefe, the director of state policies for the MPP, a pro-cannabis nonprofit that advocates for legal reforms and also tracks cannabis use by state. “In a lot of ways I think Oklahoma has among the best medical marijuana programs in the country in terms of patients having relief quickly without a bunch of hurdles they and their physicians have to jump through.”...

The OMMA as of June 17 has approved 3,211 grower, 1,548 dispensary and 859 processor licenses. Arkansas, which legalized medical cannabis in 2016, had only its third dispensary statewide open earlier this summer after lengthy legal battles over limitations on commercial licenses. “I think it helped there was a noncompetitive application process,” O’Keefe said of SQ 788, adding that “You don’t have the government deciding how many pharmacies can operate. For the most part, we let the free market decide.”...

Rollins said neither the OMMA nor the state Legislature anticipate making attempts to reduce the size of Oklahoma’s program. The Oklahoma State Board of Health last July voted to enact emergency rules that would have banned consumption by smoking and require the involvement of pharmacists in dispensaries. However, public outrage — including, in some cases, from lawmakers — and a letter from the state’s attorney general led to a reversal of those changes.

Gov. Kevin Stitt signed House Bill 2612, a lengthier framework for the medical cannabis industry, into law earlier this year. It will take effect in late August, without restrictions likely to limit patient participation, and includes state-level protections for patients who own firearms.  “I think everyone has tried to make it easier for patients to have access to the system as far as applying and how they can get recommendations,” Rollins said. “The demand is obviously there, so I think it will be interesting once we get to renewal season (this fall) on the business side to see how many have been able to sustain and become operational.”

Just another stark reminder that just how a big new law gets implemented so often is so much more important than when and how it is passes.

Notable analysis of full legalization's impact on medical marijuana regimes

The AP has this new extended article, headlined "Broad legalization takes toll on medical pot," which looks at the impact of full marijuana legalization on medical marijuana programs.  Here are some excerpts:

When states legalize pot for all adults, long-standing medical marijuana programs take a big hit, in some cases losing more than half their registered patients in just a few years, according to a data analysis by The Associated Press.

Much of the decline comes from consumers who, ill or not, got medical cards in their states because it was the only way to buy marijuana legally and then discarded them when broader legalization arrived. But for people who truly rely on marijuana to control ailments such as nausea or cancer pain, the arrival of so-called recreational cannabis can mean fewer and more expensive options....

States see a “massive exodus” of medical patients when they legalize marijuana for all adults — and then, in many cases, the remaining ones struggle, said David Mangone, director of government affairs for Americans for Safe Access. “Some of the products that these patients have relied on for consistency — and have used over and over for years — are disappearing off the shelves to market products that have a wider appeal,” he said. Cost also rises, a problem that’s compounded because many of those who stay in medical programs are low-income and rely on Social Security disability, he said.

In Oregon, where the medical program shrank the most following recreational legalization, nearly two-thirds of patients gave up their medical cards, the AP found. As patients exited, the market followed: The number of medical-only retail shops fell from 400 to two, and hundreds of growers who contracted with individual patients to grow specific strains walked away.

Now, some of the roughly 28,000 medical patients left are struggling to find affordable medical marijuana products they’ve relied on for years. While the state is awash in dry marijuana flower that’s dirt cheap, the specialized oils, tinctures and potent edibles used to alleviate severe illnesses can be harder to find and more expensive to buy....

Ten states have both medical and recreational markets. Four of them — Oregon, Nevada, Colorado, Alaska — have the combination of an established recreational marketplace and data on medical patients. The AP analysis found all four saw a drop in medical patients after broader legalization.

In Alaska, the state with the second-biggest decline, medical cardholders dropped by 63% after recreational sales began in 2016, followed by Nevada with nearly 40% since 2017 and Colorado with 19% since 2014.

The largest of all the legal markets, California, doesn’t keep data on medical patients, but those who use it say their community has been in turmoil since recreational pot debuted last year. That’s partly because the state ended unlicensed cannabis cooperatives where patients shared their homegrown pot for free....

Getting a precise nationwide count of medical patients is impossible because California, Washington and Maine don’t keep data. However, absent those states, the AP found at the end of last year nearly 1.4 million people were active patients in a medical marijuana program. The AP estimates if those states were added the number would increase by about 1 million.

As more states legalize marijuana for all adults, some who have been using it medically are feeling disenfranchised.

In Michigan, where medical marijuana has been legal for over a decade, the creation of a new licensing system for medical dispensaries has sparked court challenges as the state prepares for the advent of general marijuana sales later this year. A cancer patient there filed a federal lawsuit this month, alleging the slow licensing pace has created a shortage of the products she needs to maintain her weight and control pain.

In Washington, medical patients feel they were pushed aside when that state merged its medical and general-use markets, which also is what’s happening in California. Los Angeles dispensary owner Jerred Kiloh sells medical and recreational marijuana and said those markets are quickly becoming one, since few companies are going to produce products for a vanishing group of customers. He said his medical business has dipped to 7% of overall sales and is dropping month to month. “It’s going to be gone,” said Kiloh, president of the LA trade group United Cannabis Business Association.

New research raises questions as to relationship between medical marijuana reform and opioid overdoses

This new study just published online in the Proceedings of the National Academy of Sciences suggests that previously encouraging findings suggesting that medical marijuana reforms contributed to a reduction in opioid overdose deaths may not hold up over time.  Here is the article's abstract:

Medical cannabis has been touted as a solution to the US opioid overdose crisis since Bachhuber et al. [M. A. Bachhuber, B. Saloner, C. O. Cunningham, C. L. Barry, JAMA Intern. Med. 174, 1668–1673] found that from 1999 to 2010 states with medical cannabis laws experienced slower increases in opioid analgesic overdose mortality.  That research received substantial attention in the scientific literature and popular press and served as a talking point for the cannabis industry and its advocates, despite caveats from the authors and others to exercise caution when using ecological correlations to draw causal, individual-level conclusions. 

In this study, we used the same methods to extend Bachhuber et al.’s analysis through 2017.  Not only did findings from the original analysis not hold over the longer period, but the association between state medical cannabis laws and opioid overdose mortality reversed direction from −21% to +23% and remained positive after accounting for recreational cannabis laws.  We also uncovered no evidence that either broader (recreational) or more restrictive (low-tetrahydrocannabinol) cannabis laws were associated with changes in opioid overdose mortality.   We find it unlikely that medical cannabis — used by about 2.5% of the US population — has exerted large conflicting effects on opioid overdose mortality.  A more plausible interpretation is that this association is spurious.  Moreover, if such relationships do exist, they cannot be rigorously discerned with aggregate data.  Research into therapeutic potential of cannabis should continue, but the claim that enacting medical cannabis laws will reduce opioid overdose death should be met with skepticism.

Some discussion of this research appears in these popular press pieces, among others:

• "A cautionary tale about medical marijuana and opioid deaths"

• "The Misplaced Optimism in Legal Pot: A new study throws cold water on hopes that more liberal cannabis policies could stem the opioid epidemic."

• "Legalizing medical marijuana doesn't curb opioid overdose deaths, study says"

Americans For Safe Access releases detailed "Patient's Guide To CBD"

The leading medical marijuana advocacy group, Americans for Safe Access, has this terrific new resource titled "Patient's Guide To CBD."  Though the title of this nearly 50-page report is simple, the contents provide an intricate road-map to the complicated law and science surrounding the status and import of the cannabis-plant compound known as CBD. Here is a section of the publication's introduction:

The Patient’s Guide to CBD was created by Americans for Safe Access (ASA) for the benefit of patients, prospective patients, healthcare providers, consumers, and anyone interested in learning more about CBD.  The goal of this guide is to be an informative and useful reference document that will be shared with others so that patients, doctors, and regulators can make informed decisions regarding CBD....

Patients and consumers should also be aware of the legal and regulatory status of CBD products.  As of May 2019, 47 U.S. states have passed some type of legislation permitting the use of cannabis or cannabinoids such as CBD; nevertheless, cannabis with THC in excess of 0.3% by dry weight is a Schedule I controlled substance under U.S. Federal law.  Therefore, CBD-containing products that were produced from cannabis plants that exceed the federal threshold on THC may be legal at the state level, but are federally illegal.  Additionally, even CBD products that are derived from plants containing not more than 0.3% THC by dry weight may violate laws such as the Food, Drug and Cosmetics Act and create further legal challenges for patients and consumers.

The passage of the Agriculture Improvement Act of 2018 (also known as the 2018 Farm Bill) will make industrial hemp (i.e., cannabis with no more than 0.3% THC by dry weight), including CBD-rich industrial hemp, an agricultural commodity in the United States, but the U.S. Department of Agriculture has yet to promulgate federal regulations or approve state regulations regarding the cultivation and processing of industrial hemp. Further, the U.S. Food & Drug Administration has yet to provide a pathway for the introduction of hemp-derived CBD products into the marketplace.  Therefore, it is not yet federally legal to market hemp-derived CBD as a drug, dietary supplement, food product, or cosmetic.  Patients and consumers are encouraged to stay up to date on these changing regulations to ensure that they, and their products, are in compliance with applicable laws.

Globally, the use of products containing CBD has risen dramatically as more and more people seek alternative ways to improve their health and their lives.  The data has shown an increase in the sales of products containing CBD every year, and sales are expected to continue to rise in the coming years.

New research suggests CBD can reduce craving and anxiety for those with heroin use disorder

Long-time readers know I have long been covering the (never-quite-clear) connection between modern marijuana reform and the modern opioid crisis.  (Just some of many, many prior posts on this front are linked below.)   Today brings notable research news on this front, which is already getting a lot of attention from the mainstream press in articles from CNN, from NBC News, from Newsweek, and from US News & World Report, among others.  All these stories are about a new study published in The American Journal of Psychiatry from multiple authors under this catchy title: "Cannabidiol for the Reduction of Cue-Induced Craving and Anxiety in Drug-Abstinent Individuals With Heroin Use Disorder: A Double-Blind Randomized Placebo-Controlled Trial."  Here is the study's abstract:

Objective:

Despite the staggering consequences of the opioid epidemic, limited nonopioid medication options have been developed to treat this medical and public health crisis. This study investigated the potential of cannabidiol (CBD), a nonintoxicating phytocannabinoid, to reduce cue-induced craving and anxiety, two critical features of addiction that often contribute to relapse and continued drug use, in drug-abstinent individuals with heroin use disorder.

Methods:

This exploratory double-blind randomized placebo-controlled trial assessed the acute (1 hour, 2 hours, and 24 hours), short-term (3 consecutive days), and protracted (7 days after the last of three consecutive daily administrations) effects of CBD administration (400 or 800 mg, once daily for 3 consecutive days) on drug cue–induced craving and anxiety in drug-abstinent individuals with heroin use disorder. Secondary measures assessed participants’ positive and negative affect, cognition, and physiological status.

Results:

Acute CBD administration, in contrast to placebo, significantly reduced both craving and anxiety induced by the presentation of salient drug cues compared with neutral cues. CBD also showed significant protracted effects on these measures 7 days after the final short-term (3-day) CBD exposure. In addition, CBD reduced the drug cue–induced physiological measures of heart rate and salivary cortisol levels. There were no significant effects on cognition, and there were no serious adverse effects.

Conclusions:

CBD’s potential to reduce cue-induced craving and anxiety provides a strong basis for further investigation of this phytocannabinoid as a treatment option for opioid use disorder.

Some (of many) prior related posts:

• Two new papers provide further evidence of marijuana reform aiding with opioid crisis
• "The Case for Pot in the Age of Opioids: Legalizing medical marijuana could save lives that may otherwise be lost to opioid addiction."
• "Can medical marijuana be used to treat heroin addiction?"
• Yet another study suggests link between medical marijuana availability and decreased opioid use
• "Legalize marijuana and reduce deaths from drug abuse"
• "Obama’s Opioid Offensive Again Ignores the Cannabis Solution"
• "Is marijuana a secret weapon against the opioid epidemic?"
• "Cannabis as a Substitute for Opioid-Based Pain Medication: Patient Self-Report"
• "The use of cannabis in response to the opioid crisis: A review of the literature"
• Still more talk, from notable conservative outlets, about possible benefits of marijuana reform amidst opioid crisis
• "Could medical marijuana help fight opioid abuse? It’s complicated"
• "Impact of Medical Marijuana Legalization on Opioid Use, Chronic Opioid Use, and High-risk Opioid Use"
• "Should Physicians Recommend Replacing Opioids With Cannabis?"
• "The Impact of Cannabis Access Laws on Opioid Prescribing"
• Speculating about impact on the opioid crisis as Ohio finally sees its first legal medical marijuana sale

Encouraging research on "Medical Marijuana Laws and Suicide"

I just saw a report on this notable research reporting on the relationship between marijuana reform and suicide in California in the years before and after the legalization of medicial marijuana in 1996.  Just published in the Archives of Suicide Research, this article is titled " "Medical Marijuana Laws and Suicide," and is authored by Bradley J. Bartos, Charis E. Kubrin, Carol Newark & Richard McCleary.  Here is the article's abstract: 

Objective: To estimate the causal effect of a medical marijuana initiative on suicide risk.  In 1996, California legalized marijuana use for medical purposes. Implementation was abrupt and uniform, presenting a “natural experiment.”

Method:  Total, gun and non-gun suicides were aggregated by state for the years 1970-2004.  California’s control time series was constructed as a weighted combination of the 41 states that did not legalize marijuana during the time-frame.  Post-intervention differences for California and its constructed control time-series were interpreted as the effects of the medical marijuana law on suicide. Significance of the effects were assessed with permutation tests.

Results: The 1996 legalization resulted in mean annual reductions of 398.9 total suicides, 208 gun suicides, and 135 non-gun suicides.  The effect estimates for total and gun suicides were statistically significant (p<.05) but the effect estimate for non-gun suicides was not (p≥.488).

Conclusions: Since the effect for non-gun suicides was indistinguishable from chance, we infer that the overall causal effect was realized through gun suicides.  The mechanism could not be determined, however.  Participation in the medical marijuana program legally disqualifies participants from purchasing guns.  But since most suicides involve guns, it is possible the effect on total suicide is driven by gun suicide alone.

Shouldn't every major marijuana investor make major investments in marijuana research?

The question in the title of this post is prompted by this notable story out of Boston headlined "Harvard, MIT share $9 million gift to study marijuana's health effects." Here are the interesting details:

An investor in the cannabis industry has donated $9 million to Harvard and MIT to study the drug’s health effects, in what the institutions describe as the largest private gift to support marijuana research in the United States.  The Broderick Fund for Phytocannabinoid Research, announced Tuesday morning, will be shared equally by Harvard Medical School and the Massachusetts Institute of Technology, with the goal of filling vast gaps in the understanding of how marijuana affects the brain and behavior.

“The lack of basic science research enables people to make claims in a vacuum that are either anecdotal or based on old science,” said the donor, Charles R. “Bob” Broderick, an alumnus of both universities. “For generations we haven’t been able to study this thing for various sorts of societal reasons. That should end now, as well as the prohibitions that are falling around the world.”

Broderick has invested heavily in the booming marijuana business, starting in Canada in 2015 and more recently the United States, through his family-run Uji Capital. Although Broderick stands to profit if the studies find benefits from marijuana, the universities and the researchers said the donor will have no say in the work process or its results. They also pledged to publish their findings even if they find marijuana doesn’t help or causes harm.

Broderick recalled the first time he raised the idea of funding cannabis research with a Harvard development officer: “There was silence on the other end. Then she said, ‘I don’t think we do it.’ And I said, ‘That’s the problem.’ ” The official soon called back to say that Harvard researchers studying brain chemicals would be interested in examining marijuana’s effects.

Dr. Igor Grant, a longtime California marijuana researcher who is not involved with the Harvard-MIT project, said the grant “will really let them move forward with research that has been difficult to fund.”

“The work in this area has been very, very slow coming,” said Grant, director of the Center for Medicinal Cannabis Research at the University of California San Diego.

“This is exactly the type of research we need,” said Dr. Peter Grinspoon, a Massachusetts primary care doctor and board member of Doctors for Cannabis Regulation, a group promoting legalization and regulation of marijuana. Whether for or against marijuana, Grinspoon said, “Everybody wants more research.” The marijuana studies to date vary in quality, often have conflicting results, and typically involve either purified extracts or smoked marijuana — not the gummies, cookies, vapor, oils, or highly potent buds that people consume today....

Until recently researchers could work only with marijuana grown at a federal farm in Mississippi, whose plants are less potent than those purchased at dispensaries in states where the drug is legal. But John Gabrieli, a professor of brain and cognitive sciences at MIT and one of the grant recipients, said “a fast-changing regulatory environment” is allowing access to better material.

The MIT researchers intend to use extracts from the plants to tease out the effects of marijuana in people with schizophrenia — about half of whom are heavy cannabis users, Gabrieli said. The researchers want to pursue intriguing evidence that a component in marijuana known as tetrahydrocannabinol, or THC, improves cognitive function in people with schizophrenia. They will look at how THC as well as another key component — cannabidiol, or CBD — affect cognition alone and in combination.

Another MIT researcher will study how chronic exposure to THC and CBD may alter the cell types implicated in schizophrenia, potentially shedding light on why teens who use cannabis are at greater risk of developing schizophrenia and why the drug may be more dangerous for teens than adults.

Other studies at MIT will examine whether marijuana ingredients can help people with autism and with Huntington’s disease, and will study the effects of cannabis ingredients on attention and working memory. It’s been “incredibly hard” to get funding for marijuana research, Gabrieli said. “It’s been illegal all over the place until very recently. Without the philanthropic boost, it could take many years to work through all these issues.”

At Harvard, the $4.5 million gift establishes the Charles R. Broderick Phytocannabinoid Research Initiative, involving some 30 basic scientists and clinicians at the medical school and its affiliated hospitals. The Harvard team plans to study the effects of marijuana ingredients on brain cell function and the connections between brain cells, testing purified ingredients on mice and rats.

Researchers at Harvard have been studying natural brain chemicals known as endocannabinoids, which are involved in a variety of functions, including memory, appetite, and stress response. The grant will enable them to expand that research to encompass cannabinoids derived from plants. “Marijuana has about 100 different cannabinoid compounds. We understand very little about the specific effects of each of them on the nervous system,” said Bruce Bean, Harvard neurobiology professor and one of the project’s researchers....

The research, however, is funded by someone who could profit if the findings are favorable or lose money if new dangers are discovered.  Could knowing this somehow, even unconsciously, bias the results?  Josephine Johnston, director of research at the Hastings Center, a think tank concerned with bioethics, said such conflicts of interest are commonplace. “In a pure world, you wouldn’t have a situation like this.  But it’s pretty much a fact of life of biomedical research in the United States that you have interested parties funding research,” said Johnston, co-editor of a book on conflicts of interest in biomedical research. Institutions can enact safeguards to ensure both that the research is unbiased and that it’s perceived as trustworthy.

Both MIT and Harvard said they have such policies in place, requiring that gifts come without strings attached and that researchers have control over their work and its publication.  Grant, the California marijuana researcher, agreed that conflict of interest is an important concern. But, he added, if people profiting from the marijuana boom invest in science, “maybe that’s not a bad thing. They could just as easily buy yachts or do something else.”

Because I am a kind of marijuana researcher (focused on law and social science, rather than medical science), I realize I have a bias when suggesting that everyone involved in the marijuana industry ought to be funding academic marijuana research.  Also, as a director of the Drug Enforcement and Policy Center at The Ohio State University, I am sensitive to the concern that research funded by the marijuana industry or investors carries real conflict risks that can come with any private funding of public research. 

All that said, this article helps highlight just some of the many reasons why a lot more private funding (and a lot more public funding) is needed for all sorts of marijuana research.  There are many times I end up feeling truly overwhelmed by all the important research questions that arise in this space and all the formal and informal barriers to conducting all the needed research.   And especially with so many legal and social changes in this space, this period seems like an "all hands on deck" moment.  And I do not think it is misguided to believe that everyone involved in the marijuana industry and especially its investors ought to be swabbing the deck as best they can.

Medical marijuana proving very popular in Oklahoma

This local article spotlights the (surprising?) popularity of medical marijuana in the Sooner State under the headline "Oklahoma Medical Marijuana Authority estimated licensing 80,000 patients in year one. It's on track for 150,000."  Here are excerpts:

The Oklahoma Medical Marijuana Authority last year projected licensing 40,000 to 80,000 patients in its first year of operations. But in a surprise to OMMA personnel, the agency surpassed the 80,000-patient mark last week and could reach 150,000 by its first anniversary if the current pace of applications remains steady.

"We're probably averaging just over 5,000 a week," OMMA Director Adrienne Rollins said Thursday, which represents an increase of about 1,000 applications per week since early February, when OMMA shuttered its call center to free up time for application reviews. "We thought we would really be hammered in the very beginning and then it would start to level out. But as the number of physicians who are getting on board as far as recommending has increased, we've seen our numbers drastically increase," Rollins said. "I think at this point we're on track to have potentially 150,000."...

OMMA Communications Director Melissa Miller provided documentation to the Tulsa World showing the number of licensed patients in Oklahoma this week is more than 20 percent higher than it was the week of March 18. Miller said about 150 business license requests are submitted each week on average in recent weeks. Rollins said five OMMA employees specialize in reviewing those types of applications....

Rollins, who became the OMMA's director in October, said her department received about 3,500 patient applications between Aug. 26 and the first week of September. The number of submissions remained manageable until the winter holiday season, which is when Rollins said she noticed a "big jump" ahead of the expected widespread opening of dispensaries across the state.

By February, the OMMA closed its customer service call center, reassigning those five employees to review applications at least on a temporary basis. The move, Rollins said, means the OMMA can make decisions on up to 500 more patient applications per weekday. Of continuing to keep the call center shuttered, she said it was a "drastic change" from the OMMA's desires but maintained it was necessary to ensure applications are reviewed within the 14-day limit provided in State Question 788.

The House Rules Committee on Thursday passed a heavily amended version of Senate Bill 1030, which has a clause that if signed into law would expand the business applicant decision time to 90 days.

Spotlighting racial and regional differences in modern marijuana reform dynamics

I am very sad that presentations in my my Marijuana Law, Policy & Reform seminar have wrapped up, but that reality gives me a bit more time and space here to catch up on the marijuana law, policy and reform stories that most catch my eye.  One such important story that I missed a few weeks ago comes here from Stateline under the headline "African-Americans Missing Out on Southern Push for Legal Pot."  I recommend the extended article in full, and here are some excerpts:

Medical cannabis laws typically lay out the conditions for which the drug may be prescribed. But the laws in Arkansas and Florida — the only Southern states that have legalized medical cannabis — don’t cover sickle cell disease, which causes acute pain and disproportionately affects African-Americans. The bills advancing in Tennessee and Kentucky also exclude that condition. Three states that have legalized medical but not recreational cannabis — Connecticut, Ohio and Pennsylvania — allow sickle cell disease patients to use it....

Black legalization advocates also fear that even if medical cannabis becomes legal, white politicians won’t regulate licensing and permitting in a way that ensures equitable opportunities for people of color. “Without that, it’ll be more of the same,” said Dr. Felecia Dawson, a board-certified physician who closed her Georgia-based OB-GYN practice to focus on advocating for medical cannabis. “Legislators will keep people of color ... from the benefits of cannabis.”

Nationally, research suggests that medical marijuana use is more common among whites with high incomes, perhaps in part because of the long history of racial disparity in drug enforcement....

Every Southern state by 2016 had legalized the treatment of a limited number of conditions using CBD oil. As public support increased, so did lawmakers’ willingness to expand the list of eligible conditions. But some conditions that affect minority populations at higher rates than white ones — such as sickle cell disease, which affects 73 in 1,000 African-Americans at birth compared with 3 whites, according to federal estimates — are not included in proposals currently making their way through several Southern statehouses.

In a 2017 hearing co-hosted by the Arkansas Medical Marijuana Commission, following a ballot initiative that had legalized medical cannabis, advocates wore “Diversity for All” T-shirts to emphasize the drug’s importance to minority residents. “We know that such diseases as hypertension, sickle cell, neuropathy and so on are more predominant in blacks,” Casey Caldwell, a black cannabis advocate, said at the hearing.

“It is safe to say that African-American communities would benefit the most,” she added. “In the past, pharmaceutical drugs have been priced so high that [we] have to make a decision whether or not they should eat or whether they should purchase medication.”

Those concerns echoed what Dee Dawkins-Haigler, a former Democratic Georgia representative who headed the state’s Black Caucus, said in 2015 about the initial absence of black people among the state’s 17 appointees to the Commission on Medical Cannabis. The Black Caucus eventually fought to get sickle cell disease added to the list of conditions eligible for CBD oil....

In Florida, black farmers initially cried foul at being shut out of the state’s multibillion-dollar cannabis trade over policies that required license holders to have operated for 30 straight years. According to Roz McCarthy, founder of the Florida-based advocacy group Minorities for Medical Marijuana, the state’s law lacked the teeth needed to ensure that medical cannabis license holders adhered to requirements to ensure diversity in hiring. A spokesperson for the Florida Department of Health said that state law “does not require medical marijuana treatment centers to report the race or ethnicity of its owners.”

McCarthy said, “We’re trying to push lawmakers to understand that they have the ability and the power to ensure exclusionary practices don’t happen. Barriers are there. But the opportunity to reduce barriers is also there.”

Critically and skeptically examining the claims in support of medical marijuana

The third planned presentations from a student in my Marijuana Law, Policy & Reform seminar this coming week will, in his words, "marshal the tools of critical thinking and scientific skepticism against the mounting claims about medical marijuana."  Here is how this student explains his plans and suggested background reading:

I have noticed worrying signs in the medical cannabis industry that bear all the hallmarks of pseudoscience and “alternative medicine.” For example, how many ailments fall under the ever-broadening curative umbrella of CBD? The ability to think critically and skeptically is the most useful skill we have as humans for discerning the truth, and it is most important to engage such skills when our biases most threaten our steady course. Remember the frequent allusions this semester to those who embrace medical legalization as a stepping stone to recreational use? Such people may be more inclined to jettison their critical thinking capabilities when it comes to scrutinizing claims in whose outcome one holds an interest.

I will provide a brief primer on thinking critically and skeptically, and then describe the signs of pseudo-scientific reasoning. Then, armed with this toolkit of sorts, I will explore the various claims about the benefits of cannabis as a medicine, including the current research, its blind spots, and its shortcomings. I will then critically explore the ethics and policy behind prohibition, comparing and contrasting cannabis with prescription drugs and alcohol; we shall see how the claimed justifications for cannabis prohibition stand up to critical scrutiny.

Links to Reading Matter

It is not vital that people read anything prior to the presentation, but here are some useful links for those wishing to get ahead of the game:

• Steven Novella et al., The Skeptics’ Guide to the Universe 57–140 (2018).

Of course, I understand that people might not have access to the above-mentioned book, in which case the following website will suffice (although I commend the book highly in its entirety to anyone interested in how we get at the truth of things).

• "Logical Fallacies," The Skeptics Guide to the Universe (last visited Apr. 7, 2019).

• Scott Gavura, "Medical Marijuana: Where’s the Evidence?," Science-Based Medicine (Jan. 11, 2018)

• Steven Novella, "Marijuana Beliefs Outstrip Evidence," Science-Based Medicine (July 25, 2018)

• Salomeh Keyhani, MD, MPH; Stacey Steigerwald, MSSA; Julie Ishida, MD, MAS; Marzieh Vali, MS; Magdalena Cerdá, DrPH; Deborah Hasin, PhD; Camille Dollinger, BS; Sodahm R. Yoo, BS; Beth E. Cohen, MD, MAS, "Risks and Benefits of Marijuana Use: A National Survey of U.S. Adults," American College of Physicians: Annals of Internal Medicine (Sept. 4, 2018)

• Peter Grinspoon, "Cannabidiol (CBD) — what we know and what we don’t," Harvard Health Publishing: Harvard Health Blog (Aug. 24, 2018)

Federal scheduling and research challenges for cannabis and psychedelics

The second of four student presentation this coming week in my Marijuana Law, Policy & Reform seminar will focus on  federal scheduling under the Controlled Substances Act and the research and market realities impacted by the placement of marijuana in Schedule I.  Here is how my student has summarized his topic, along with the background readings he has provided:

The placement of cannabis in Schedule I practically prevents comprehensive and meaningful research into its medical applications and potential harms.  The federal government cites cannabis' placement in Schedule I as the reason rigorous research must be conducted before it can be rescheduled, but places restrictions on its research, because of its schedule, that are nearly impossible to overcome.  Is there an alternative pathway to federal cannabis legalization, or at least rescheduling, so that more meaningful research can be conducted? 

My presentation will examine U.S. drug scheduling, looking at the criteria and examples of substances in each schedule.  I will then provide an overview of the FDA research model by which new drugs come to market, contrast it with the type of research conducted on cannabis, and discuss why meaningful, rigorous research into cannabis is so difficult.  With this background, I will discuss the findings of a former UK drug-policy adviser that suggests substantial rescheduling is necessary, and how these findings helped initiate research into other Schedule I drugs.  Finally, I will provide an overview of research into other Schedule I substances, particularly psychedelics, and how this research may accelerate the rescheduling or federal legalization of cannabis so that its impact on health may be studied more effectively.

Background Resources:

• FDA website on "The Drug Development Process"

• NAS Chapter on "Challenges and Barriers in Conducting Cannabis Research"

• Links to academic research on psychedelics

• Website for Multidisciplinary Association for Psychedelic Studies (MAPS)

• "Psychedelic medicine: a re-emerging therapeutic paradigm"

• "The abuse potential of medical psilocybin according to the 8 factors of the Controlled Substances Act"

• "Psychedelic Mushrooms Are Closer to Medicinal Use (It’s Not Just Your Imagination)"

• "Government drug adviser David Nutt sacked: Professor David Nutt asked to resign after his claims that ecstasy and LSD were less dangerous than alcohol"