• Home cultivation of medical marijuana can result in higher hospitalizations and emergency department visits related to opioids

      03/30/2021
      guest contributor

    Jayani Jayawardhana, PhD, is an associate professor at the University of Georgia College of Pharmacy (@JayJayawardhana). Jose M. Fernandez, PhD, is an associate professor at the University of Louisville College of Business (@UofLEcon).

    Before the COVID pandemic, the United States was in the midst of an opioid epidemic. A menu of health policies has been recommended to battle the rising cases of opioid overdoses including prescription drug monitoring programs (PDMPs), increasing access to naloxone (an opioid antagonist), and pain management clinic laws. Surprisingly, another set of policies adopted by some states—though not intended as a response to the opioid epidemic—was found to be effective in reducing opioid prescriptions: medical marijuana policies (MMPs).

    A new study, published this month in Health Services Research, contributes to the literature on medical marijuana by examining the relationship between medical marijuana policies and hospitalizations and emergency department (ED) visits related to opioids while accounting for different types of medical marijuana policies.

    Background

    Medical marijuana policies take different forms, including permitting active dispensaries to sell medical marijuana and allowing home cultivation of medical marijuana. These policies differ in how much access they afford patients. Access contingent on dispensaries often means needing to register as a patient, gaining access to medical marijuana card, and being able to afford the cost of medical marijuana since it is not covered through health insurance. Furthermore, dispensaries may not be easily accessible for all users.

    Home cultivation provides easier access to marijuana by allowing patients to grow marijuana at home. Although home cultivation policies may limit the number of plants that can be grown and the maturity level of plants at a given household, home cultivation provides access to marijuana at almost no cost except for the initial cost of purchasing plants/seeds for cultivation.

    Previous literature has emphasized the importance of accounting for these specific types of policies when studying medical marijuana since they are different from each other. Existing research on MMPs have found states with home cultivation of medical marijuana only to be associated with reductions in opioid prescriptions among Medicare enrollees. While a few studies have found MMPs to be associated with reductions in opioid-related mortality, opioid-related hospitalizations, and opioid prescriptions among Medicaid enrollees, these studies have not accounted for different types of MMPs.

    Methods

    We used state-level quarterly data from Healthcare Cost and Utilization Project’s Fast Stats database to gain access to ED and inpatient visit rates by state. These data were linked with changes in medical marijuana polices in states from 2005 to 2016. Along with the medical marijuana polices, we controlled for a long list of state policies used to combat the opioid crisis including presence of PDMP, mandatory access of PDMP by providers, pain management clinic laws, Good Samaritan laws, availability of naloxone without a prescription, recreational marijuana policy implementation, and Medicaid expansion. In addition, we controlled for state socio-demographic characteristics such as unemployment rate, percent uninsured, population size, median household income, ethanol consumption per capita, and beer taxes.

    We used a difference-in-differences regression approach to compare changes in opioid-related inpatient and ED visit rates per 100,000 population before and after a state has implemented a given MMP to those states that did not implement the given MMP. A key identifying assumption was that parallel trends existed in inpatient and ED visit rates among states that implemented MMPs (treatment) and states that did not implement MMPs (control) prior to policy implementation; an event study showed no significant difference between treatment and control groups prior to policy implementation.

    Findings

    The results of our study showed that states that allow home cultivation of medical marijuana experienced about 12% increase in opioid-related hospitalizations and about 44% increase in opioid-related ED visits compared with states without home cultivation of medical marijuana. However, study results did not find significant associations between medical marijuana dispensaries and opioid-related hospitalizations and ED visits.

    We further disaggregated home cultivation into two categories, unsupervised and requiring a permit. We found unsupervised home cultivation to be associated with an increase of 15.6% in inpatient hospitalizations related to opioids though requiring a permit for home cultivation was not significantly associated with hospitalizations. These findings indicate that easier access to marijuana through unsupervised home cultivation may result in adverse health outcomes needing further treatment.

    Additionally, implementation of recreational marijuana policy was associated with about 16-17% increase in opioid-related hospitalizations, while it had no significant association with opioid-related ED visits. Access to naloxone without a prescription was significantly associated with an 8% increase in opioid-related hospitalizations though it was not significantly associated with opioid-related ED visits. While naloxone may help reduce mortality by reversing opioid overdoses, individuals that experience overdoses may seek healthcare at inpatient setting. Thus, it is not surprising that availability of naloxone is associated with increased opioid-related hospitalizations.

    There are a few limitations in this study. The study uses state-level aggregated data for inpatient and ED visits from only 47 states and 35 states respectively for the period of 2005-2016. Identifying specific reasoning behind opioid-related hospitalizations and ED visits or the source of drugs such as prescription or illicit (i.e., heroin) that resulted in those visits was not possible due to the aggregate nature of the data.

    Conclusions

    Despite these limitations, the findings of this study provide an important contribution to the policy debate on medical marijuana legalization. The findings indicate that increased access to marijuana via home cultivation is associated with increases in opioid-related hospitalizations and ED visits, suggesting that easier access to marijuana among opioid users may result in adverse health conditions that need treatment at inpatient or ED settings.

    While it remains unclear whether marijuana liberalization may be a beneficial public health tool in the fight against the opioid epidemic, the results of this study support the argument that potential benefits and adverse health outcomes associated with different types of MMPs should be taken into consideration when discussing marijuana as a policy alternative in addressing the opioid epidemic.

     
      Health Policy
      emergency department, hospitalization, marijuana, opioids
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  • Can Marijuana Help with Opioid Addiction?

      08/18/2020
      Tiffany Doherty

    Part 3 of our opioid series, supported by the NIHCM Foundation, examines the potential of marijuana to improve outcomes in opioid addiction therapy. Some studies have suggested that marijuana can ease the path to shaking opioid dependence, but more recent data might be telling us a different story.

     

    @DrTiff_PhD

     
      Health Policy
      Healthcare Triage, marijuana, Opioid crisis, opioids
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  • Marijuana and The Risk of Stroke

      01/04/2020
      Tiffany Doherty

    Sources like WebMD would have you believing that smoking pot drastically increases your risk of stroke. Let’s see what sources like Healthcare Triage think about that.

     

    @DrTiff_

     
      Life
      Healthcare Triage News, marijuana, Stroke risk
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  • Cannabis Use Among Teens in the Age of Social Media

      12/05/2019
      Alex Woodruff

    Alex Woodruff is a Policy Analyst at Boston University School of Public Health. He tweets at @aewoodru.

    Marketing has a powerful effect on shaping teens’ behavior. With recreational cannabis use legalized in many states, and on track to becoming legal in more, advertisement regulations could shape teens’ exposure to cannabis marketing.

    Cannabis marketing is booming. The industry is rapidly growing in the social media space for product promotion, especially to young audiences. Social media influencers display cannabis products as a key component to a complete and healthy life, with artfully crafted edibles, CBD lattes and lotions to fit the consumers’ taste. There are entire lifestyle brands that promote cannabis and CBD (one of the chemicals in marijuana without any psychoactive effects) as a treatment for anything from menstrual cramps to depression. These advertisements are readily available to teens and are undoubtedly alluring. It would be easy for teens to view cannabis products as a holistic treatment for the rising rates of anxiety and depression or simply as way to connect with trends on social media.

    But one of the few areas of consensus among public health officials and doctors about the effects of marijuana is that it is harmful to developing brains. Cannabis use among teens is associated with decreased cognitive functioning and psychosis later in life. Multiple organizations including the American College of Pediatricians and the American College of Adolescent Psychology have opposed legalization efforts on the basis that it puts teens at risk.

    While the causal effect of cannabis marketing on teens is unclear, it is established that the more time teens spend engaging with a product’s marketing — by following accounts, wearing branding, and sharing ads with friends, for instance — the higher the odds are that they use that product.

    Public health officials and activists have spent decades trying to protect teens from tobacco and alcohol marketing by encouraging restrictions on the types and locations of advertising for these products. But social media has changed the game. Ads are no longer generic TV commercials and billboards, but instead are targeted messages that latch on to viewers’ known interests.

    A group of researchers from across the country including Dr. Pamela Trangenstein, Dr. Jennifer Whitehill, Marina C. Jenkins, Dr. David Jernigan, and Dr. Megan Moreno, looked at how much teens in states with legalized non-medical cannabis are exposed to cannabis marketing. They found that over 90% were exposed to at least some kind of marketing. The majority came, unsurprisingly, from social media.

    New Research

    This same group of researchers recently took a deep dive into the relationship between cannabis marketing and teen use. (The authors of this study are affiliated with Boston University School of Public Health’s Department of Health Law, Policy and Management, University of North Carolina at Chapel Hill, University of Massachusetts Amherst, and University of Wisconsin Madison.) Across multiple states with legalized non-medical cannabis, they asked teens how much they interact with cannabis advertisements in their day-to-day lives and how that links to cannabis use.

    Using online surveys, they asked 482 teens, aged 15-19 years, questions about their experience with cannabis branding and social media. For example, they asked if teens were actively following social media accounts with marijuana marketing. Probing deeper, researchers asked teens what their favorite cannabis brand was, how likely they were to own or wear a cannabis branded item, and the extent that they used cannabis products.

    The researchers found that over a third of teens in states with legalized non-medical cannabis were interacting with cannabis promotions on social media. Teens were actively and intentionally following certain cannabis business pages on Instagram, Twitter, and Facebook. Instagram had the largest following, with Facebook close behind. Roughly a third of respondents said they were likely to own or wear a branded product, and 20 percent reported having a favorite brand.

    Overall, about a third of teens surveyed reported using marijuana in the past year. Teens that said that they like or follow a brand on social media were five times more likely to have used cannabis in the past year compared to their non-engaged peers. Those who said they do or would own a branded item were seven times more likely to have used cannabis in the past year. Those with a favorite brand were eight times more likely. Youth who reported past-year cannabis use did not differ by gender, race, or ethnicity, but were more likely report having parents with less than a bachelor’s degree.

    These findings underscore the link between youth and marketing. Teens who interact with marketing are much more likely to use cannabis products, putting them at greater risk for the mental health outcomes described above.

    Conclusions

    The explosion of legal cannabis brands means that there is a lot of interest in finding new ways to advertise products and gain an edge in the market. To date, there is significant variation in the restrictions states have adopted on cannabis advertisements. For example, Colorado has several restrictions on internet, pop-up, location-based, and out-of-state advertising, while Alaska has none.

    Plus, each social media platform has its own restrictions on cannabis advertising. For example, advertising cannabis on Facebook is banned, but a policy change in 2018 allows users to search and follow cannabis-related pages. Instagram users can search tags such as #legalmarijuana or #CBD and find hundreds of blogs and places to buy products.

    The new research suggests that we need to better understand how teens interact with cannabis advertisements. The evident variation in state marketing restrictions indicates there is a lack of consensus among policymakers on how best to protect this highly-susceptible group from harmful promotions. More data are needed to better determine how these advertisements can be effectively restricted to protect teens. It is a huge undertaking, but as we learned from tobacco and alcohol, it’s worth the effort.

     
      Health Policy
      advertising, HLPM pubs, marijuana, public health, teens
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  • Can Marijuana Help Cure the Opioid Crisis?

      06/19/2019
      Austin Frakt

    The following originally appeared on The Upshot (copyright 2019, The New York Times Company). 

    The idea that legal cannabis can help address the opioid crisis has generated much hope and enthusiasm.

    Opioid misuse has declined in recent years at the same time that cannabis use has been increasing, with many states liberalizing marijuana laws.

    Based on recent research, some advocates have been promotingthis connection, arguing that easier access to marijuana reduces opioid use and, in turn, overdose deaths.

    A new study urges caution. Sometimes appearances — or statistics — can be deceiving.

    It’s plausible that marijuana can help reduce pain. Systematicreviews show that certain compounds found in marijuana or synthetically produced cannabinoids do so, at least for some conditions. So some people who might otherwise seek out opioid painkillers could use medical marijuana instead.

    Regulations in some states, including New York, that streamline access to medical marijuana are based on the idea that it can substitute for opioids in pain treatment.

    In 2014, a study published in JAMA gave further hope that liberalizing marijuana laws might alleviate the opioid crisis.

    The study examined the years 1999 through 2010, during which 10 states established medical marijuana programs. It compared changes in the rates of opioid painkiller deaths in states that passed medical marijuana laws with those that had not. The results? Researchers found that the laws were associated with a nearly 25 percent decline in the death rate from opioid painkillers.

    Since publication of the JAMA study, others have produced similar findings. One posted last fall at the Social Science Research Network found that counties with medical marijuana dispensaries have up to 8 percent fewer opioid-related deaths among non-Hispanic white men, and 10 percent fewer heroin deaths.

    Other studies have documented marijuana laws associated withreduced opioid prescribing in Medicaid and Medicare.

    None of this proves that marijuana liberalization causes lower opioid-related mortality, something the authors of the 2014 JAMA study pointed out.

    Correlation does not mean causation, of course. A particular challenge in interpreting correlations in social science has its own name — the ecological fallacy. It’s the erroneous conclusion that relationships observed at the wider level (like state or region) necessarily hold true at the individual level as well.

    “It’s possible that relationships get strengthened, weakened or even reversed when going from the individual to aggregate level,” said Mark Glickman, senior lecturer on statistics at Harvard. This was documented in a classic paper in 1950 and underlies many erroneous conclusions from research.

    A new study revisited the JAMA-published analysis with more data. Its conclusions cast doubt on the idea that medical marijuana helps reduce opioid deaths — at least as far as we can tell with state-level data.

    Between 2010 — the final year of analysis in the JAMA study — and 2017, 32 more states legalized medical marijuana, and eight legalized recreational use. A new study published in the Proceedings of the National Academy of Sciences (P.N.A.S.) reassessed the relationship between these laws and opioid deaths using the same approach as the JAMA study, but extending the years of analysis through 2017.

    Over the years analyzed in the JAMA study, 1999 to 2010, the new P.N.A.S. study produced similar findings: Medical marijuana legalization was associated with reduced opioid painkiller overdose deaths. But in an expanded analysis through 2017, the results reversed — the laws are associated with a 23 percent increase in deaths.

    This doesn’t necessarily mean that the laws first saved lives and then, in later years, contributed to deadly overdoses.

    @afrakt

     
      Explaining Research, Health Policy
      marijuana, opioids, Upshot
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  • Healthcare Triage: The Reality of Legal Weed and Crime Increases

      02/12/2019
      Aaron Carroll

    There has been a lot of news lately about increasing crime in states where recreational marijuana has been legalized. Crime is rising in some of these states, but it doesn’t seem to be tied to the legal weed. We lay out all the relevant research.

    This episode was adapted from a column I wrote for the Upshot. Links to sources can be found there.

    @aaronecarroll

     
      Health Policy
      crime, Healthcare Triage, marijuana, pot, Upshot
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  • The Reasonable Way to View Marijuana’s Risks

      01/17/2019
      Aaron Carroll

    The following originally appeared on The Upshot (copyright 2019, The New York Times Company).

    Are we underestimating the harms of legalizing marijuana?

    Those who hold this view have been in the news recently, saying that research shows we are moving too far too fast without understanding the damage.

    America is in the midst of a sea change in policies on pot, and we should all be a bit nervous about unintended consequences.

    Vigilance is required. But it should be reasoned and thoughtful. To tackle recent claims, we should use the best methods and evidence as a starting point.

    Crime has gone up in Colorado and Washington since those states legalized marijuana. It’s reasonable to wonder about the connection, but it’s also reasonable to be skeptical about causation.

    The best method to investigate this may be synthetic controls. Researchers can use a weighted combination of similar groups (states that are like Colorado and Washington in a number of ways) to create a model of how those states might have been expected to perform with respect to crime without any changes in marijuana laws. Benjamin Hansen, a professor of economics at the University of Oregon, used this methodology to create a comparison group that most closely resembled the homicide trends and levels from 2000-12.

    “I picked those years because they were after the tremendous crime drop in the early ’90s and most predictive of crime today,” he said. “I ended in 2012 because that’s when Colorado and Washington voted to legalize marijuana.”

    This model showed that we might have predicted more of an increase in Colorado or Washington just based on trends seen in comparable states, even without legalization. When he compared the two states with the synthetic control, Colorado and Washington actually had lower rates after legalization than you’d expect given trends.

    This is not evidence that legalization lowers crime rates. But it does suggest that we shouldn’t conclude that it increases them. A number of other studies agree.

    A potential misperception involves automobile crashes. Drunken drivers are measurably impaired when their blood alcohol level is above a certain level. We can prove this in randomized controlled trials.

    The tests we use for measuring the presence of THC, though, do not measure the level of impairment. They measure whether someone has used marijuana recently. If we legalize the drug, and more people use it, more people will register its recent use even when they are not impaired. So it should be expected that more people involved in car crashes will test positive even if no one is driving while high.

    Using a synthetic control approach, Mr. Hansen and colleagues showedthat marijuana-related fatality rates did not increase more after legalization than what you would expect from trends and other states.

    Dr. Ziva Cooper is one of the authors of the National Academies of Sciences, Engineering, and Medicine’s comprehensive report on cannabis.

    She says some have misinterpreted the report to state that the report’s committee concluded that cannabis causes schizophrenia. It did not.

    “This was stated as an association, not causation,” she said. “We do not yet have the supporting evidence to state the direction of this association.”

    Dr. Cooper, research director of the U.C.L.A. Cannabis Research Initiative, went further: “We as a committee also concluded that a history of cannabis use is associated with better cognitive outcomes in people diagnosed with psychotic disorders. The blatant omission of this conclusion exemplifies the one-sided nature of some articles. Nonetheless, the strong association between cannabis use and schizophrenia means that people with predisposing risk factors for schizophrenia should most certainly abstain from using cannabis.”

    No one should be under the impression that marijuana is harmless. The potential downsides are well known, and I’ve covered them. Nor should anyone be irrationally exuberant about its upsides. It’s not a wonder drug, and the proven benefits are also minimal (as I discussed here).

     
      Explaining Research
      drugs, evidence, harms, marijuana, pot, Upshot
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  • A more thorough analysis of marijuana use and homicide in Colorado and Washington

      01/08/2019
      guest contributor

    I was annoyed by much of the media coverage recently on the dangers of marijuana. I was contacted by Benjamin Hansen, W.E. Miner Professor of Economics, University of Oregon, who wrote this post. TIE readers are simply the best. – @aaronecarroll

    Correlation is not causation.  These are the oft-repeated lines almost anyone can utter when they don’t agree with a statistic they come across.  Recently, the book “Tell Your Children: The Truth About Marijuana, Mental Illness, and Violence,” has attracted both fierce fans and foes, based on its Amazon review rating which sits at exactly 3, with an even split of 1-star and 5-star reviews. When can we trust a correlation tells us something about causation? That’s where randomization helps.  However, for many studies randomization isn’t feasible due to either financial, political, or ethical constraints.

    Such is the case with marijuana and how it relates to violence in humans.  It is ILLEGAL to randomize exposure to marijuana for humans due to both marijuana’s scheduling and institutional review boards that require researchers seek to “maximize benefits while minimizing harm”.  Even if one could legally do this research, actually measuring impacts on violence might be impossible, because relatively few people commit violent crimes.  Putting this in context, there are only 4.9 murders per 100,000 people in the United States.  So even if we did a large scale randomized study of 10,000 participants with high compliance costing millions of dollars, we could never know anything about murder and weed.  Likewise, assault rates are roughly 250 per 100,000, so we’d only pick up effects on assaults if the impacts were gigantic.

    All of the constraints above are why social scientists have often relied upon quasi-experimental methods.  These methods allow researchers to construct control groups to try to predict what would have happened in the absence of medical treatment, a law change, or a new policy regime. Given the recent debate surrounding “Tell Your Children: The Truth About Marijuana, Mental Illness, and Violence,” I decided to ask if the data supported the violence-marijuana hypothesis.  Using the approach of Abadie, Diamond, and Hainmuller, I predicted the best synthetic Colorado and synthetic Washington based on a weighted average of states that closely follow Colorado and Washington’s trends.  Below I plot the figures of each state relative to their synthetic counterpart.

    While it is true that homicide rates went up in CO and WA more than they rose for the nation as a whole, the homicide rates in Colorado and Washington were actually below what the data predicted they would have been given the trends in homicides from 2000-2012.

    This suggests, at best, we can’t conclude that marijuana legalization increases violence, and perhaps even there could be small negative effects. You might say, naturally, “That’s fine.  But could these approaches or other related approached reasonably have picked up increases in violence if they were present?  The answer is “yes”, and they already have, but for another drug: alcohol.  Anderson, Crost, and Rees found violent crime increased in Kansas after they legalized access to alcohol statewide in 1986.  Moreover, Carpenter and Dobkin found arrests for assault jump by 11 percent when people get access to alcohol (see figure 3 from their manuscript) using arrest records from California.  We replicated these findings using similar data from Oregon.

    Does this mean we shouldn’t caution our children about marijuana abuse and dependence? Of course not.  But it is also worth noting the sky isn’t falling in Colorado and Washington, at least any more than what we have predicted had they not legalized in the first place.

    @benconomics

     
      Health Policy
      crime, homicide, marijuana
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  • Healthcare Triage News: Election Results Impact the ACA, Medicaid Expansion, and Marijuana

      11/07/2018
      Aaron Carroll

    Yesterday’s election results have a lot of impact on health care in the United States. The new Democratic House of Representatives and the ACA, expansion of Medicaid in red states, and medical and recreational marijuana are all affected by last nights returns.

    @aaronecarroll

     
      Health Policy
      ACA, election, Healthcare Triage, marijuana, Medicaid expansion, politics
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  • Healthcare Triage: The Harms of Marijuana

      06/12/2018
      Aaron Carroll

    We’ve talked in the past about the positives of Marijuana use. What are the harms? From pregnancy effects to impaired driving to memory and concentration, Aaron will tell you how pot might hurt you.

    This episode was adapted from a column I wrote for The Upshot. Links to sources can be found there.

    @aaronecarroll

     
      Explaining Research, Health Policy
      harms, Healthcare Triage, marijuana, pot, Upshot
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