United States marijuana legalization and opioid mortality trends before and during the first year of the COVID-19 pandemic
DOI:
https://doi.org/10.5055/jom.0829Keywords:
marijuana medicinal legalization, marijuana recreational legalization, United States opioid mortality epidemic, fentanyl, coronavirus disease 2019 pandemicAbstract
Background: To determine if marijuana legalization was associated with reduced opioid mortality.
Study design: The United States (US) opioid mortality trend during the 2010-2019 decade was compared in states and District of Columbia (jurisdictions) that had implemented marijuana legalization with states that had not. Acceleration of opioid mortality during 2020, the first year of the coronavirus disease 2019 (COVID-19) pandemic, was also compared in recreational and medicinal-only legalizing jurisdictions.
Methods: Joinpoint methodology was applied to the Centers for Disease Control and Prevention WONDER data. Trends in legalizing jurisdictions were cumulative aggregates.
Results: The overall opioid and fentanyl death rates and the percentage of opioid deaths due to fentanyl increased more during 2010-2019 in jurisdictions that legalized marijuana than in those that did not (pairwise comparison p = 0.007, 0.05, and 0.006, respectively). By 2019, the all-opioid and fentanyl death rates were 44 and 50 percent greater in the legalizing than in the nonlegalizing jurisdictions, respectively. When the COVID-19 pandemic hit in 2020, jurisdictions that implemented recreational marijuana legalization before 2019 had significantly greater increases in both overall opioid and fentanyl death rates than jurisdictions with medicinal-only legalization. For all-opioids, the mean (95 percent confidence interval) 2019-to-2020 increases were 46.5 percent (36.6, 56.3 percent) and 29.1 percent (20.2, 37.9 percent), respectively (p = 0.02). For fentanyl, they were 115.6 percent (80.2, 151.6 percent) and 55.4 percent (31.6, 79.2 percent), respectively (p = 0.01).
Conclusions: During the past decade, marijuana legalization in the US was associated at the jurisdiction level with a greater acceleration in opioid death rate. An even greater increase in opioid mortality occurred in recreational-legalizing jurisdictions with the onset of the COVID-19 pandemic. Marijuana legalization is correlated with worsening of the US opioid epidemic.
References
Victor B, Hager K, Stacy S: Re-legalizing cannabis for medical use in the USA. J Public Health (Oxf). 2022; 44(3): 679-684. DOI: 10.1093/pubmed/fdab066. DOI: https://doi.org/10.1093/pubmed/fdab066
State Medical Cannabis Laws, National Conference of State Legislatures (NCSL): Available at https://www.ncsl.org/research/health/state-medical-marijuana-laws.aspx#3. Accessed May 15, 2023.
Arnold JF, Sade RM: Regulating marijuana use in the United States: Moving past the gateway hypothesis of drug use. J Law Med Ethics. 2020; 48(2): 275-278. DOI: 10.1177/1073110520935339. DOI: https://doi.org/10.1177/1073110520935339
The United States Department of Justice: Presidential proclamation on marijuana possession. Available at https://www.justice.gov/pardon/presidential-proclamation-marijuanapossession. Accessed May 15, 2023.
Statista: Sales of legal recreational cannabis in the United States from 2021 to 2026. Available at https://www.statista.com/statistics/933384/legal-cannabis-sales-forecast-us/. Accessed May 15, 2023.
Dills A, Goffard S, Miron J, et al.: The effect of state marijuana legalizations: 2021 update. 2021. Available at https://www.cato.org/policy-analysis/effect-state-marijuana-legalizations-2021-update. Accessed May 18, 2023.
Bleyer A, Barnes B, Finn K: United States marijuana legalization and opioid mortality epidemic during 2010-2020 and pandemic implications. J Natl Med Assoc. 2022; 114(4): 412-425. DOI: 10.1016/j.jnma.2022.03.004. DOI: https://doi.org/10.1016/j.jnma.2022.03.004
Kaufman DE, Nihal AM, Leppo JD, et al.: Opioid mortality following implementation of medical cannabis programs in the United States. Pharmacopsychiatry. 2021; 54(2): 91-95. DOI: 10.1055/a-1353-6509. DOI: https://doi.org/10.1055/a-1353-6509
Athanassiou M, Dumais A, Zouaoui I, et al.: The clouded debate: A systematic review of comparative longitudinal studies examining the impact of recreational cannabis legalization on key public health outcomes. Front Psychiatry. 2023; 13: 1060656. DOI: 10.3389/fpsyt.2022.1060656. DOI: https://doi.org/10.3389/fpsyt.2022.1060656
Centers for Disease Control and Prevention, National Center for Health Statistics: Multiple cause of death 1999-2020 on CDC WONDER online database, released in 2021. Data are from the Multiple Cause of Death Files, 1999-2020, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. Available at http://wonder.cdc.gov/mcd-icd10.html. Accessed May 15, 2023.
Statistical Research and Applications Branch, National Cancer Institute: Joinpoint regression program, version 4.9.0.0. March 2021; Kim HJ, Fay MP, Feuer EJ, et al.: Permutation tests for joinpoint regression with applications to cancer rates. Stat Med. 2020; 19: 335-351. DOI: https://doi.org/10.1002/(SICI)1097-0258(20000215)19:3<335::AID-SIM336>3.3.CO;2-Q
Powell D, Pacula RL, Jacobson M: Do medical marijuana laws reduce addictions and deaths related to pain killers? J Health Econ. 2018; 58(March): 29-42. DOI: 10.1016/j.jhealeco.2017.12.007. DOI: https://doi.org/10.1016/j.jhealeco.2017.12.007
Martins SS, Segura LE, Levy NS, et al.: Racial and ethnic differences in cannabis use following legalization in US states with medical cannabis laws. JAMA Netw Open. 2021; 4(9): E2127002. DOI: 10.1001/jamanetworkopen.2021.27002. DOI: https://doi.org/10.1001/jamanetworkopen.2021.27002
Office of Cannabis Policy. State of Maine Office of Administrative and Financial Services: Available at https://www.maine.gov/dafs/omp/adult-use. Accessed May 15, 2023.
Wikipedia: Cannabis in Michigan. Available at https://en.wikipedia.org/wiki/Cannabis_in_Michigan. Accessed May 15, 2023.
Wikipedia: Cannabis in Massachusetts. Available at https://en.wikipedia.org/wiki/Cannabis_in_Massachusetts. Accessed May 15, 2023.
Georgia Department of Public Health: Low THC oil registry. Available at https://dph.georgia.gov/low-thc-oil-registry. Accessed May 15, 2023.
Wikipedia: Cannabis in Georgia. Available at https://en.wikipedia.org/wiki/Cannabis_in_Georgia_(U.S._state). Accessed May 15, 2023.
Wikipedia: Cannabis in Louisiana. Available at https://en.wikipedia.org/wiki/Cannabis_in_Louisiana. Accessed May 15, 2023.
Wikipedia: Cannabis in [state name]. 2023. Available at https://en.wikipedia.org/wiki/cannabis_in_[statename]. Accessed May 15, 2023.
Louisiana Department of Health: Regulating medical marijuana. Available at https://ldh.la.gov/assets/oph/Rulemaking/noi/Medical_Marijuana_NOI_cv_Register.pdf. Accessed May 15, 2023.
Schauer GL, Dilley JA, Roehler DR, et al.: Cannabis sales increases during COVID-19: Findings from Alaska, Colorado, Oregon, and Washington. Int J Drug Policy. 2021; 98: 103384. DOI: 10.1016/j.drugpo.2021.103384. DOI: https://doi.org/10.1016/j.drugpo.2021.103384
Scavone JL, Sterling RC, Van Bockstaele EJ: Cannabinoid and opioid interactions: Implications for opiate dependence and withdrawal. Neuroscience. 2013; 248: 637-654. DOI: 10.1016/j.neuroscience.2013.04.034. DOI: https://doi.org/10.1016/j.neuroscience.2013.04.034
Tanda G, Pontieri FE, Di Chiara G: Cannabinoid and heroin activation of mesolimbic dopamine transmission by a common μ1 opioid receptor mechanism. Science. 1997; 276(5321): 2048-2050. DOI: https://doi.org/10.1126/science.276.5321.2048
Ashton CH: Pharmacology and effects of cannabis: A brief review. Br J Psychiatry. 2001; 178: 101-106. DOI: 10.1192/bjp.178.2.101. DOI: https://doi.org/10.1192/bjp.178.2.101
Secades-Villa R, Garcia-Rodríguez O, Jin CJ, et al.: Probability and predictors of the cannabis gateway effect: A national study. Int J Drug Policy. 2015; 26(2): 135-142. DOI: 10.1016/j.drugpo.2014.07.011. DOI: https://doi.org/10.1016/j.drugpo.2014.07.011
Macha V, Abouk R, Drake C: Association of recreational cannabis legalization with alcohol use among adults in the US, 2010 to 2019. JAMA Health Forum. 2022; 3(11): e224069. DOI: 10.1001/jamahealthforum.2022.4069. DOI: https://doi.org/10.1001/jamahealthforum.2022.4069
Braymiller JL, Riehm KE, Meier M, et al.: Associations of alternative cannabis product use and poly-use with subsequent illicit drug use initiation during adolescence. Psychopharmacology. 2023; DOI: 10.1007/s00213-023-06330-w. DOI: https://doi.org/10.1007/s00213-023-06330-w
Thrul J, Rabinowitz JA, Reboussin BA, et al.: Adolescent cannabis and tobacco use are associated with opioid use in young adulthood 12-year longitudinal study in an urban cohort. Addiction. 2021; 116(3): 643-650. DOI: 10.1111/add.15183. DOI: https://doi.org/10.1111/add.15183
Olfson M, Wall MM, Liu SM, et al.: Cannabis use and risk of prescription opioid use disorder in the United States. Am J Psychiatry. 2018; 175(1): 47-53. DOI: 10.1176/appi.ajp.2017.17040413. DOI: https://doi.org/10.1176/appi.ajp.2017.17040413
Ali MM, McClellan C, Mutter R, et al.: Recreational marijuana laws and the misuse of prescription opioids: Evidence from national survey on drug use and health microdata. Health Econ. 2023; 32(2): 277-301. DOI: 10.1002/hec.4620. DOI: https://doi.org/10.1002/hec.4620
Bachhuber MA, Saloner B, Cunningham CO, et al.: Medical cannabis laws and opioid analgesic overdose mortality in the United States, 1999-2010. JAMA Intern Med. 2014; 174(10): 1668-1673. DOI: 10.1001/jamainternmed.2014.4005. DOI: https://doi.org/10.1001/jamainternmed.2014.4005
Livingston MD, Barnett TE, Delcher C, et al.: Recreational cannabis legalization and opioid-related deaths in Colorado, 2000-2015. Am J Public Health. 2017; 107(11): 1827-1829. DOI: https://doi.org/10.2105/AJPH.2017.304059
Kim JH, Martins SS, Shmulewitz D, et al.: Association between fatal opioid overdose and state medical cannabis laws in US national survey data, 2000-2011. Int J Drug Policy. 2022; 99(January): 103449. DOI: 10.1016/j.drugpo.2021.103449. DOI: https://doi.org/10.1016/j.drugpo.2021.103449
Liang D, Bao Y, Wallace M, et al.: Medical cannabis legalization and opioid prescriptions: Evidence on US Medicaid enrollees during 1993-2014. Addiction. 2018; 113(11): 2060-2070. DOI: 10.1111/add.14382. DOI: https://doi.org/10.1111/add.14382
Bradford AC, Bradford WD, Abraham A, et al.: Association between US state medical cannabis laws and opioid prescribing in the Medicare part D population. JAMA Intern Med. 2018; 178(5): 667-672. DOI: 10.1001/jamainternmed.2018.0266. DOI: https://doi.org/10.1001/jamainternmed.2018.0266
Wen J, Wen H, Butler JS, et al.: The impact of medical and recreational marijuana laws on opioid prescribing in employer-sponsored health insurance. Health Econ. 2021; 30(5): 989-1000. DOI: 10.1002/hec.4237. DOI: https://doi.org/10.1002/hec.4237
Bao Y, Zhang H, Bruera E, et al.: Medical marijuana legalization and opioid- and pain-related outcomes among patients newly diagnosed with cancer receiving anticancer treatment. JAMA Oncol. 2023; 9(2): 206-214. DOI: 10.1001/jamaoncol.2022.5623. DOI: https://doi.org/10.1001/jamaoncol.2022.5623
Hsu G, Kovács B: Association between county level cannabis dispensary counts and opioid related mortality rates in the United States: Panel data study. BMJ. 2021; 372: M4957. DOI: 10.1136/bmj.m4957. DOI: https://doi.org/10.1136/bmj.m4957
Castillo-Carniglia A, Rivera-Aguirre A, Santaella-Tenorio J, et al.: Changes in opioid and benzodiazepine poisoning deaths after cannabis legalization in the US: A county-level analysis, 2002-2020. Epidemiology. 2023; 34: 467-475. DOI: 10.1097/EDE.0000000000001609. DOI: https://doi.org/10.1097/EDE.0000000000001609
Monnat SM, Peters DJ, Berg MT, et al.: Using census data to understand county-level differences in overall drug mortality and opioid-related mortality by opioid type. Am J Public Health. 2019; 109: 1084-1091. DOI: 10.2105/AJPH.2019.305136. DOI: https://doi.org/10.2105/AJPH.2019.305136
Marinello S, Powell LM: The impact of recreational cannabis markets on motor vehicle accident, suicide, and opioid overdose fatalities. Soc Sci Med. 2023; 320: 115680. DOI: 10.1016/j.socscimed.2023.115680. DOI: https://doi.org/10.1016/j.socscimed.2023.115680
McMichael BJ, Van Horn RL, Viscusi WK: The impact of cannabis access laws on opioid prescribing. J Health Econ. 2020; 69: 102273. DOI: 10.1016/j.jhealeco.2019.102273. DOI: https://doi.org/10.1016/j.jhealeco.2019.102273
Mathur NK, Ruhm CJ: Marijuana legalization and opioid deaths. J Health Econ. 2023; 88: 102728. DOI: 10.1016/j.jhealeco.2023.102728. DOI: https://doi.org/10.1016/j.jhealeco.2023.102728
Flexon JL, Stolzenberg L, D'Alessio SJ: The effect of cannabis laws on opioid use. Int J Drug Policy. 2019; 74: 152-159. DOI: 10.1016/j.drugpo.2019.09.013.0. DOI: https://doi.org/10.1016/j.drugpo.2019.09.013
Harton MR, Adams ZW, Parker MA: Associations of alcohol use disorder, cannabis use disorder, and nicotine dependence with concurrent opioid use disorder in US adults. Exp Clin Psychopharmacol. 2023; DOI: 10.1037/pha0000649. DOI: https://doi.org/10.1037/pha0000649
Alley ZM, Kerr DCR, Bae H: Trends in college students' alcohol, nicotine, prescription opioid and other drug use after recreational marijuana legalization: 2008–2018. Addict Behav. 2020; 102: 106212. DOI: 10.1016/j.addbeh.2019.106212. DOI: https://doi.org/10.1016/j.addbeh.2019.106212
Khalid SI, Jiang S, Khilwani H, et al.: Postoperative opioid use among opioid-naïve cannabis users following single-level lumbar fusions. World Neurosurg. 2023; 175(23): e644-e652. DOI: 10.1016/j.wneu.2023.04.001. DOI: https://doi.org/10.1016/j.wneu.2023.04.001
Drake C, Wen J, Hinde J, et al.: Recreational cannabis laws and opioid-related emergency department visit rates. Health Econ. 2021; 30: 2595-2605. DOI: 10.1002/hec.4377. DOI: https://doi.org/10.1002/hec.4377
Stevens AJ, Higgins MD: A systematic review of the analgesic efficacy of cannabinoid medications in the management of acute pain. Acta Anaesthesiol Scand. 2017; 61(3): 268-280. DOI: 10.1111/aas.12851. DOI: https://doi.org/10.1111/aas.12851
Meng H, Johnston B, Englesakis M, et al.: Selective cannabinoids for chronic neuropathic pain: A systematic review and meta-analysis. Anesth Analg. 2017; 125(5): 1638-1652. DOI: 10.1213/ANE.0000000000002110. DOI: https://doi.org/10.1213/ANE.0000000000002110
Bhashyam AR, Heng M, Harris MB, et al.: Self-reported marijuana use is associated with increased use of prescription opioids following traumatic musculoskeletal injury. J Bone Joint Surg. 2018; 100(24): 2095-2102. DOI: https://doi.org/10.2106/JBJS.17.01400
Tormohlen KN, Bicket MC, White S, et al.: The state of the evidence on the association between state cannabis laws and opioid-related outcomes: A review. Curr Addict Rep. 2021; 8(4): 538-545. DOI: 10.1007/s40429-021-00397-1. DOI: https://doi.org/10.1007/s40429-021-00397-1
Segura LE, Mauro CM, Levy NS, et al.: Association of US medical marijuana laws with nonmedical prescription opioid use and prescription opioid use disorder. JAMA Netw Open. 2019; 2(7): e197216. DOI: 10.1001/jamanetworkopen.2019.7216. DOI: https://doi.org/10.1001/jamanetworkopen.2019.7216
Caputi TL, Humphreys K: Medical marijuana users are more likely to use prescription drugs medically and non-medically. J Addict Med. 2018; 12(4): 295-299. DOI: 10.1097/ADM. DOI: https://doi.org/10.1097/ADM.0000000000000405
Li G, Chihuri S: Is marijuana use associated with decreased use of prescription opioids? Toxicological findings from two US national samples of drivers. Subst Abuse Treat Prev Policy. 2020; 15(1): 12. DOI: 10.1186/s13011-020-00257-7. DOI: https://doi.org/10.1186/s13011-020-00257-7
Shover CL, Davis CS, Gordon SC, et al.: Association between medical cannabis laws and opioid overdose mortality has reversed over time. Proc Natl Acad Sci USA. 2019; 116(26): 12624-12626. DOI: https://doi.org/10.1073/pnas.1903434116
Alcocer JJ: Exploring the effect of Colorado's recreational marijuana policy on opioid overdose rates. Public Health. 2020; 185: 8-14. DOI: 10.1016/j.puhe.2020.04.007. DOI: https://doi.org/10.1016/j.puhe.2020.04.007
Wang GS, Buttorff C, Wilks A, et al.: Comparison of hospital claims and poison center data to evaluate health impact of opioids, cannabis and synthetic cannabinoids. Am J Emerg Med. 2022; 53: 150-153. DOI: 10.1016/j.ajem.2022.01.004. DOI: https://doi.org/10.1016/j.ajem.2022.01.004
Buttorff C, Wang GS, Wilks A, et al.: Impact of recreational cannabis legalization on opioid prescribing and opioid-related hospital visits in Colorado: An observational study. J Gen Intern Med. 2023; 38(12): 2726-2733. DOI: 10.1007/s11606-023-08195-3. DOI: https://doi.org/10.1007/s11606-023-08195-3
Lo SY, Winston-McPherson GN, Starosta AJ, et al.: Cannabis legalization does not influence patient compliance with opioid therapy. Am J Med. 2019; 132(3): 347-353. DOI: 10.1016/j.amjmed.2018.11.002. DOI: https://doi.org/10.1016/j.amjmed.2018.11.002
Rhew IC, Le VT, Ramirez JJ, et al.: The association between cannabis use and risk of non-medical pain reliever misuse onset among young adults in a legal cannabis context. Addict Behav. 2023; 143: 107711. DOI: 10.1016/j.addbeh.2023.107711. DOI: https://doi.org/10.1016/j.addbeh.2023.107711
Williams AR, Mauro CM, Feng T, et al.: Adult medical cannabinoid use and changes in prescription controlled substance use. Cannabis Cannabinoid Res. 2022; 8: 933-941. DOI: 10.1089/can.2021.0212. DOI: https://doi.org/10.1089/can.2021.0212
Gorfinkel LR, Stohl M, Greenstein E, et al.: Is cannabis being used as a substitute for non-medical opioids by adults with problem substance use in the United States? A within-person analysis. Addiction. 2021; 116(5): 1113-1121. DOI: 10.1111/add.15228. DOI: https://doi.org/10.1111/add.15228
Goedel WC, Macmadu A, Shihipar A, et al.: Association of medical cannabis licensure with prescription opioid receipt: A population-based, individual-level retrospective cohort study. Int J Drug Policy. 2022; 100: 103502. DOI: 10.1016/j.drugpo.2021.103502. DOI: https://doi.org/10.1016/j.drugpo.2021.103502
Palfai TP, Tahaney KD, Winter MR: Is marijuana use associated with health promotion behaviors among college students? Health-promoting and health-risk behaviors among students identified through screening in a university student health services center. J Drug Issues. 2016; 46: 41-50. DOI: https://doi.org/10.1177/0022042615610619
Meinhofer A, Witman A, Murphy SM, et al.: Medical marijuana laws are associated with increases in substance use treatment admissions by pregnant women. Addiction. 2019; 114(9): 1593-1601. DOI: 10.1111/add.14661. DOI: https://doi.org/10.1111/add.14661
Moon AS, LeRoy TE, Yacoubian V, et al.: Cannabis use is associated with increased use of prescription opioids following posterior lumbar spinal fusion surgery. Global Spine J. 2022; 14: 204-210. DOI: 10.1177/21925682221099857. DOI: https://doi.org/10.1177/21925682221099857
Franklyn AM, Eibl JK, Gauthier GJ, et al.: The impact of cannabis use on patients enrolled in opioid agonist therapy in Ontario, Canada. PLoS One. 2017; 12(11): e0187633. DOI: 10.1371/journal.pone.0187633. DOI: https://doi.org/10.1371/journal.pone.0187633
Bramness JG, Hjellvik V, Stubhaug A, et al.: Possible opioid-saving effect of cannabis-based medicine using individual-based data from the Norwegian prescription database. Basic Clin Pharmacol Toxicol. 2021; 130: 84-92. DOI: 10.1111/bcpt.13660. DOI: https://doi.org/10.1111/bcpt.13660
Sznitman S, Mabouk C, Said Z, et al.: Opioid and healthcare service use in medical cannabis patients with chronic pain: A prospective study. BMJ Support Palliat Care. 2021; 13: e464-e468. DOI: 10.1136/bmjspcare-2020-002661. DOI: https://doi.org/10.1136/bmjspcare-2020-002661
Campbell G, Hall WD, Peacock A, et al.: Effect of cannabis use in people with chronic non-cancer pain prescribed opioids: Findings from a 4-year prospective cohort study. Lancet Public Health. 2018; 3: e341-350-e350. DOI: https://doi.org/10.1016/S2468-2667(18)30110-5
Wilson J, Mills K, Freeman TP, et al.: Weeding out the truth: A systematic review and meta-analysis on the transition from cannabis use to opioid use and opioid use disorders, abuse or dependence. Addiction. 2022; 117(2): 284-298. DOI: 10.1111/add.15581. DOI: https://doi.org/10.1111/add.15581
Wadsworth E, Hines LA, Hammond D: Legal status of recreational cannabis and self-reported substitution of cannabis for opioids or prescription pain medication in Canada and the United States. Subst Abus. 2022; 43(1): 943-948. DOI: 10.1080/08897077.2022.2060431. DOI: https://doi.org/10.1080/08897077.2022.2060431
Published
How to Cite
Issue
Section
License
Copyright 2005-2024, Weston Medical Publishing, LLC
All Rights Reserved
