Medical marijuana laws could be a boon to those battling the opioid epidemic, according to researchers who have identified a link between increased access to medical marijuana and a reduction in opioid prescriptions.
The studies suggest medical marijuana laws (MMLs) have helped save and could continue to save thousands of lives and billions of dollars now being lost to opioid addiction.
There is a downside: The promise of MMLs in reducing opioid use shows up thus far in urban areas, but not in rural America.
The marijuana laws have an effect similar to when any replacement for a drug is introduced, say researchers. In this case, marijuana appears to be a substitute for opioids as a pain medication in many cases.
This week the JAMA’s Journal of Internal Medicine published two studies that conclude that medical marijuana (or medical cannabis) laws have the potential to reduce opioid prescriptions. One study looked at Medicare Part D patient data and the other at Medicaid enrollee data.
The Medicare study (Association Between US State Medical Cannabis Laws and Opioid Prescribing in the Medicare Part D Population by Ashley C. Bradford, BA; W. David Bradford, PhD; Amanda Abraham, PhD; and Grace Bagwell Adams, PhD, at the University of Georgia) found that opioid prescriptions fell in states that permit medical marijuana. Prescriptions filled for all opioids decreased by 2.11 million daily doses per year from an average of 23.08 million daily doses per year when a state instituted any medical cannabis law. Prescriptions for all opioids decreased by 3.742 million daily doses per year when medical cannabis dispensaries opened.
A second JAMA Journal study (Association of Medical and Adult-Use Marijuana Laws With Opioid Prescribing for Medicaid Enrollees, by Hefei Wen, PhD, and Jason M. Hockenberry, PhD, Department of Health Management & Policy, University of Kentucky College of Public Health) found that “medical and adult-use marijuana laws have the potential to reduce opioid prescribing for Medicaid enrollees, a segment of population with disproportionately high risk for chronic pain, opioid use disorder, and opioid overdose.” Using Medicaid prescription data for 2011 to 2016, the researchers found lower opioid prescribing rates where there were medical marijuana laws (5.88 percent lower) and adult-use marijuana laws (6.38 percent lower).
One of the MML researchers, Dr. W. David Bradford, discussed his past and recent research into medical marijuana and opioid prescriptions as well as other research at the Workers’ Compensation Research Institute (WCRI) annual symposium last week in Boston.
Among Bradford’s observations: the effect of MMLs on lowering opioid prescribing, while encouraging, is not fairly distributed.
“All of this is happening in urban areas. We can find no benefit, in this or any of our studies in rural America. As is often the case, people in rural sections of the country are getting a little left out from innovations,” Bradford said.
Bradford is the George D. Busbee Chair in Public Policy at the University of Georgia and former director and founder of the Center for Health Economic Policy Studies at the Medical University of South Carolina. He has been a visiting faculty member at Yale Medical School, and a tenured faculty member in the Department of Economics at the University of New Hampshire. Dr. Bradford has over 70 publications.
Bradford and his fellow researchers, including his daughter who is also a professor, looked at whether medical marijuana is being used as a substitute for other pain medications including opioids, as well as the effect this usage has on spending and on opioid mortality.
“We wanted to compare changes in pain medication use for people in states that don’t have medical cannabis and how those changes compare to the changes for people in states with medical cannabis laws,” he said of their first foray into the field.
They considered whether the state allows home cultivation or requires dispensaries. With dispensary-based distribution, it’s a lot easier to have “surety of the supply, a lot easier to get very finely defined hybrids that have the particular mix of cannabinoids,” according to Bradford.
They reviewed Medicare Part D enrollee data from 2010 to 2014 and then later updated this to include 2015 data. The number of states with an MML grew from 15 in 2010 to 24 over these years. They compared physician prescriptions in states with and without an MML for nine drug groupings: anxiety, depression, glaucoma, nausea, pain, psychosis, seizures, sleep disorders and spasticity.
In their analysis, they found that the use of prescription pain drugs fell significantly after a medical marijuana law went into effect. There were 1,230 fewer annual doses for all pain medications for these conditions per physician under all medical marijuana laws. They found 2,338 fewer daily doses per year for dispensary-based laws and 1,193 fewer daily doses per year for home-cultivation-only laws.
In their recent follow-up research, they focused specifically on opioid prescriptions. They found about a nine percent reduction in opioid prescriptions under any MML – but a higher 14 percent reduction in states with dispensaries. There was about a seven percent reduction in home cultivation states.
As Bradford puts it, when MMLs are implemented, use of prescription drugs falls “just as would happen if any effective new drug were approved by the FDA [Federal Drug Administration].”
Bradford and his colleagues did similar research using Medicaid data and came to the same conclusion that MMLs reduce use of prescriptions and opioids.
However, one troubling finding is that nearly all of the effect is happening in counties with more than 50,000 residents. “There was no benefit for rural counties,” he said.
They also calculated the financial impact. The combined 2014 savings to Medicare and Medicaid were $1.04 billion for states that had MMLs. Bradford said this could have been savings of $3.4 billion if all states had an MML.
“So these are nontrivial savings to Medicaid and Medicare – about one and a half percent of prescription spending is possibly diverted away from the programs,” he said, noting that the enrollees are the ones paying for the marijuana, not the payers.
They also have conducted research that is under review on the effect of MMLs on opioid-related deaths, using data on all non-heroin opiate related deaths for all 3,144 counties in the U.S. from 2000 to 2015. For all prescription opioid related deaths, they found: statistically significant reductions in mortality associated with any MML for all years from 2010 to 2015 in all counties together and no statistically significant effects in rural counties. For only non-synthetic opioid related deaths (i.e., no fentanyl) they found statistically significant reductions in mortality associated with any MML and with dispensary-based laws for all years from 2010 to 2015 in all counties together.
“We’re looking at somewhere in the neighborhood of a 20 to 30 percent reduction in mortality over what it would be,” Bradford said.
Bradford referred to a 2014 study by researchers at Albert Einstein Medical School in New York that also found a connection between MML states and a reduction in opioid deaths. This study (Study on the relationship between medical cannabis laws and opioid analgesic overdose deaths) reviewed 1999-2010 data from 23 states with MMLs. The authors compared opioid overdose death rates in states with medical cannabis programs to overdose deaths rates in states with no cannabis laws. They found about a 25 percent reduction, which translated to an estimated 1,729 fewer deaths than expected. The authors excluded opioid deaths from suicide and included overdose deaths related to heroin, since heroin and prescription opioid use are interrelated for some individuals.
“It looks like access to cannabis, when you design the policies appropriately, can save both lives and money,” Bradford told the WCRI audience.
“But again, in rural counties, there is zero estimated effect. We’re not finding any benefit in terms of mortality for the rural counties,” he reiterated.
Federal Marijuana Policy
Currently cannabis is listed in the Controlled Substances Act under Schedule 1, which means that it is a drug along with LSD, peyote heroin and others that have been “deemed to have no medically recognized uses and a high potential for abuse and therefore completely illegal.” It’s the most restrictive category. Physicians cannot prescribe cannabis, people cannot possess it, no one can sell it under federal law.
The view that marijuana has no medically recognized uses was challenged in January of 2017, when the National Academy of Scientific Engineering and Medicine published what Bradford considers a landmark study. The NAS reviewed more than 10,000 peer-reviewed clinical publications to determine whether there is sufficient evidence to draw conclusions regarding the medical application of cannabis.
“What they concluded is that there is indeed conclusive evidence that there are benefits to cannabis for chronic pain in adults, for nausea associated with chemotherapy and for spasticity and seizures. There is moderate evidence for many other conditions,” Bradford said.
The 2017 NAS report is “quite good evidence that cannabis is useful and, of course, what this implies is that a fine reading of the Controlled Substances Act would reschedule cannabis away from Schedule 1 and then to probably a 3 or a 4. That would be a level that physicians could prescribe it and could get involved.”
The Trump Administration has taken a harder line against legalized marijuana than did the Obama Administration, thereby complicating how medical marijuana laws and usage may play out. Currently 29 states and D.C., representing two-thirds of the U.S. population, have some form of medical cannabis law that runs counter to federal policy.
Public opinion on the subject has largely been supportive of legalizing marijuana for medical use. A January Quinnipiac Poll found that 91 percent of Americans support allowing people with their doctor’s assistance to get access to cannabis. The same poll found voters oppose 70 to 23 percent enforcing federal marijuana laws in states that have legalized medical or recreational marijuana.
Workers’ Comp Reimbursement
The workers’ compensation industry has generally been focused on the impact of medical marijuana on employees and safety in the workplace. As Bradford noted, patients, not insurers, are typically the ones now paying for their medical marijuana, even where it is a replacement for an opioid prescription.
There have been several court decisions approving reimbursement by health insurers or self-insured employers but for the most part states have remained silent on the matter of if and when reimbursement by an insurer or workers’ compensation carrier is allowed or required.
However, even in this uncertain legal environment, medical marijuana is gaining traction as an accepted treatment paid for by workers’ compensation, at least anecdotally, according to experts in a recent Claims Journal interview.
Brian Allen, vice president of government affairs for Mitchell, and Mark Pew, senior vice president of PRIUM, a division of Genex Services, said there is some reimbursement for medical marijuana being done on a voluntary basis when it is deemed a reasonable and necessary treatment. “The decision is really based on whether that patient is achieving benefit from it,” Pew said.
Pew said that carriers paying for medical marijuana treatment are not necessarily making it public.
When such cases reach courts, Allen thinks judges will be reluctant to get in the middle of a doctor-patient relationship. “I think the courts are going to defer to the doctors every time,” said Allen.
Pew agrees. “I think any court is probably going to lean towards the anecdotal story of the individual patient and if it’s helping with their pain and it’s reasonable and necessary based on the advice of doctors in that state,” he told Claims Journal. “I would assume that most states are going to come to that same conclusion.”
While marijuana is still illegal at the federal level, the Trump Administration has indicated that marijuana enforcement will be at the discretion of local assistant U.S. attorneys. Allen believes it’s unlikely they will pursue a medical marijuana case, unless there is some “egregious abuse.”
Both agree that for marijuana to become a more widely accepted alternative to opioids, researchers will have to shed light on the drug’s side effects. “They talk about the pluses. We really don’t hear a lot about the minuses, and we know there are some out there,” Allen said.
Pew believes more research needs to be done into the many chemicals within marijuana. “Just saying we’re going to reclassify marijuana or make it legal — it’s much more complicated,” Pew said.
That cautious view appears consistent with what the National Council on Compensation Insurance (NCCI) concluded in a recent status update on medical marijuana and workers’ compensation by David Deitz, PhD:
“The medical use of cannabis and cannabinoids presents both potential benefits as well as harms for injured workers. These need to be evaluated for each individual patient in the context of other medical and psychosocial issues, along with the possible impacts on safe return to work. Employer policies will need to evolve with changes in science, law, and regulation. With millions of Americans using cannabis daily and more studies in progress, we should not have to wait long for new data.”