By Dr. Mitch Freeman, PharmD, Chief Clinical Officer, Mitchell International Pharmacy Solutions
The U.S. Surgeon General’s recent advisory on marijuana use during adolescence and pregnancy highlights a critical perspective in the push to legalize marijuana: we still do not yet know enough about the drug.
As the opioid crisis continues and states look for ways to reduce prescribing of and addiction to opioids, marijuana has repeatedly surfaced as a potential alternative in pain management. While some smaller-scale findings suggest that medical marijuana could be an effective way to manage pain, there still is not sufficient long-term clinical research to confirm that it is a viable solution.
One part of the Surgeon General’s advisory states, “While CBD is not intoxicating and does not lead to addiction, its long-term effects are largely unknown, and most CBD products are untested and of uncertain purity.” This is important to highlight as the workers’ compensation industry continues to consider whether medical marijuana is a viable option for pain management.
Although the advisory is specific to pregnant women and adolescents, the fact that we need to understand more about the drug applies widely. States continue to legalize or expand the legalization of marijuana, while clinical research lags behind. In 2019, more than 700 bills were considered across the United States related to cannabis. Yet, only a few studies have emerged recently to show the benefits or drawbacks of marijuana and its legalization.
Let’s take a look at a few recent studies.
Some studies have found that cannabis can be an effective treatment for chronic pain.
Notably, a review from JAMA of 79 trials on the effectiveness of marijuana found that there was moderate evidence to suggest that cannabis is effective at treating chronic pain. Another study found that cannflavins, components of the cannabis plant, are thirty times more effective at treating pain than aspirin. Although there is not enough abundance of cannflavins in a single weight of cannabis to provide therapeutic benefits, researchers have found a way to metabolically engineer the cannflavins. This is an interesting step in research of the plant and its possible therapeutic benefits. Again, more research needs to be done to assess the true opportunity of these chemicals as alternative analgesics.
However, research has been conflicted on whether or not marijuana use reduces opioid use and rates of opioid overdose.
One study, published in The Journal of Bone & Joint Surgery, looked at self-reported use of marijuana during patients’ recovery from musculoskeletal injuries. The findings in this study contradict the belief that the availability of marijuana will reduce opioid use. In fact, the study found that patients who used marijuana during their recovery actually had higher rates of opioid use. Additionally, opioid prescription duration was longer for those who used marijuana during their recovery than for those who did not use marijuana (90 days versus 15 days, respectively).
A study from Pain Medicine looking at concurrent opioid and marijuana use from patients with chronic pain found that patients who used opioids and marijuana at the same time were at a higher risk for opioid misuse.
Several studies have also looked at the rate of opioid overdoses in states that legalized marijuana. An initial study from JAMA Internal Medicine, published in 2014, found that, in states with legalized medical marijuana, opioid overdose deaths were 25 percent lower than in states that had not legalized marijuana. However, a similar study that was released in 2018 in the Proceedings of the National Academy of Sciences and included data through 2017 found the opposite: opioid overdose death rates were actually higher in states that had legalized medical marijuana. In this period, legalization increased moderately: twenty-three states (plus Washington DC) had legalized medical marijuana by 2014 versus 30 by 2017.
Data from Colorado, which has had legal medical marijuana since 2001, shows that opioid overdose deaths have steadily increased in the state, even after legalization of recreational marijuana in 2012.
Yet another study, published in the JAMA Internal Medicine journal, found that the rate of opioid prescriptions in states with legal marijuana dropped, suggesting a decline in opioid use and abuse in those states. In analyzing Medicaid prescription data (2011-2016), the researchers found that, in states with medical marijuana laws, opioid prescribing was 5.88% lower. States with legal recreational marijuana saw a 6.38% decrease in the prescribing of opioids. The authors of the research note, however, that they “do not know whether patients actually avoided or reduced opioid use because of increased access to cannabis.”
More Research is Needed
It is important to note that, although many of these studies show a correlation between marijuana legalization and opioid use or abuse, they do not prove causation. Other factors may be at play in the increase or decrease in opioid overdoses in certain states. The lack of controlled clinical trials to clarify the true benefits and side effects of medical marijuana makes it difficult to determine if the drug is actually valuable or detrimental to patients and society.
The findings across these studies underline the need for more research. Recent changes at the federal level suggest we may soon get just that: the DEA announced at the end of August that it would start processing pending applications to grow marijuana for scientific research. As of now, scientists can only obtain marijuana for research from the University of Mississippi.
Regardless of opinion on the drug, marijuana continues to be a hot topic in workers’ compensation and across the country. As more becomes known about its effects and applications, we are sure to see more action taken at the state and federal level.
About Mitch Freeman
Mitch Freeman is the Chief Clinical Officer for Mitchell International, Pharmacy Solutions. Prior to joining Mitchell, Freeman was the CEO of First Coast Health. He has a wealth of industry expertise and leadership in the workers’ compensation industry including the chief sales and marketing officer of PMSI, vice president of sales at Ameritox, vice president and general manager for ExpressScripts, and president of pharmacy services for MSC.
Freeman is a frequent guest speaker and author. Freeman is a graduate of Florida A&M University where he received his doctorate of pharmacy.
Headquartered in San Diego, California, Mitchell International, Inc. delivers smart technology solutions that simplify and accelerate claims handling and repair processes, driving more accurate, consistent and cost-effective resolutions. Mitchell integrates deep industry expertise into its workflow solutions, providing unparalleled access to data, advanced analytics and decision support tools. Mitchell’s comprehensive solution portfolio and robust SaaS infrastructure connect its customers in ways that enable tens of millions of electronic transactions to be processed each month for more than 300 insurance companies, over 30,000 collision repair facilities and countless other Property & Casualty industry supply partners across the Americas and Europe. For more information, please visit mitchell.com.
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