Death due to opioid overdose is now the 5th leading cause of mortality for Americans, more than motor vehicle accidents or by guns. According to the CDC, Americans now have a 1 in 96 chance of dying by opioid overdose, meaning that most of us have a friend or relative who has been impacted by opioid abuse and addiction. While some progress has been made in recent years, government interventions aimed at controlling the opioid epidemic have proven to be too little too late, and over a fifteen-year period ending in 2017 more than a third of a million Americans have died from opioids. However, an optimistic observation has been made, which may lead to more dramatic reductions in opioid-related deaths: that the rates of opioid consumption decrease in states which pass legalized medical and recreational marijuana laws.
A new study published in the Journal of Health Economics in January of 2020 analyzed the data of over 1.5 billion opioid prescriptions between 2011 and 2018 and found that in states with legal medical cannabis reduced relative opioid use by 11.3%, and those with recreational cannabis laws by a further 4.3%. They found that the laws reduced the total days of opioid supply, the total number of patients receiving opioids, and the probability of a patient being prescribed opioids in the first place. These findings support the work of other researchers who have found that, in states with legal medical or recreational cannabis, opioid-related deaths decrease and so does the cost of public healthcare (such as Medicare and Medicaid) for taxpayers. These findings suggest that the legalization of cannabis can reduce drug-related injuries or deaths while simultaneously reducing the burden of medical treatment on federal and state budgets.
Opioid-Related Deaths in the US
Drug overdoses are a major cause of death for Americans, with some of the highest rates in the world. A 2019 study found that the rates of drug overdoses in this country are 3.5 times higher than any of the other 17 'high-income' countries of the world. In a 2018 report using the Center for Disease Control (CDC) data, between 1999 and 2016 there were 632,331 deaths from drug overdoses. Of those, more than half were from opioids (351,630 deaths). Between 2000 and 2015, the number of opioid prescriptions in the US quadrupled, over that same time period the number of deaths due to prescription opioids increased five-fold. According to the CDC, in 2017, there were 70,237 drug overdose deaths, 47,600 of which were caused by opioids such as morphine, oxycodone, and fentanyl. The states with the highest rates of death were West Virginia, Ohio, Pennsylvania, the District of Colombia, and Kentucky.
Over the last two decades, there have been three waves of opioid deaths, the first was the early 1990’s when Oxycodone and Oxycotin (made by Purdue Pharma) became widely prescribed across the country. The second wave began in 2010 with a dramatic rise in heroin-related deaths as prescriptions become harder to get. The third wave of deaths came just 3 years later when highly potent synthetic opioids such as illegally manufactured fentanyl became cheap and easily accessible.
Opioid-related deaths peaked in 2017 with 130 people every day, with 60% of those deaths due to prescription opioids. Non-prescription opioid deaths would be those that derive from heroin or illegally manufactured fentanyl and fentanyl analogs. Today, fentanyl and the even more powerful carfentanil can be found in a wide range of street drugs, and in 2016 accounted for at least 30.5% of all drug-related deaths.
The problem has become so severe, that a November 2019 publication in the Journal of the American Medical Association reported that US life expectancy, which had increased from 69.9 years to 78.9 years from 1959 to 2016 had actually decreased from 2010-2017. This decrease was attributed primarily to drug overdoses, alcohol abuse, and suicides. Interestingly, the greatest rise in overdoses was seen in the 'Ohio Valley'states (West Virginia, Ohio, Indiana, and Kentucky). States which are also known for their strict anti-marijuana policies.
Opioid Usage in the Legal Cannabis States
As mentioned above, opioid deaths peaked in 2017, and although there has been no major decline, the rates have stabilized, thus intriguing researchers to ask why. In 2017, there were 70,699 drug overdose deaths, and in 2018 that decreased by 4.7% to 67,316 deaths, reversing the trend of the last 18 years. Although many in our government would like to claim that Prescription Drug Monitoring Programs (PDMPs) have contributed to this decline, many researchers say the data does not support those conclusions. In fact, many point out that it was these interventions that led to the second and third waves of the opioid epidemic, as government controls pushed patients towards acquiring the unregulated and more dangerous heroin or synthetic opioids from the black market.
In the most current CDC data, over the period from June 2018 to June 2019, drug overdoses in the US only decreased by 0.2%, with a high amount of heterogeneity between states. Of the ten states with the highest increases in drug overdoses, only 2 have legal recreational cannabis. Of the 10 states with the highest decreases in overdoses rates, 8 have legalized medical cannabis. Cannabis has been used for more than a thousand years for the treatment of pain, and in the largest systematic meta-review ever undertaken on the topic (published by the Journal of American Medical Society in 2015), it was concluded based on the analysis of 79 trials involving more than 6,460 patients that cannabis was significantly effective at relieving pain when compared with a placebo. And furthermore, that it was safe and had few serious side-effects. This fact, coupled with the demographic info presented above would lead to the logical conclusion that cannabis liberalization would lead to lower rates of opioid addiction and overdose. However, correlation does not imply causation, so more evidence of this relationship was needed.
That brings us back to the study published earlier this month. In this study, the authors used a metric of Morphine Milligram Equivalents (MME) to measure the number of opioids prescribed in each state studied. This value represents a factor of the strength of the prescription, the quantity prescribed, and the days over which it is consumed. This was then compared to data regarding when individual states enacted cannabis legalization policy, and whether it was only for medical purposes or included recreational use. The study pointed out that the states which provided a safer alternative to opioids saw higher decreases in opioid-related deaths than those which merely attempted to decrease the number of prescriptions through tighter control policies.
Another interesting topic explored in the paper is that of economic cost to public healthcare systems. Citing other studies, the paper noted that cannabis legalization reduced opioid prescriptions anywhere from 5.9 to 11.8% in 2014, which equaled a nearly $1 billion decrease in state Medicaid costs.
Another study from 2017showed that in states with legal cannabis, there was a 23% decrease in hospital admissions related to opioid use. Furthermore, studies found that, in states that decriminalized cannabis, the incidence of road accidents where drivers tested positive for opioids also decreased. This means that a potential unintended consequence of cannabis legalization is decreased economic and social burdens due to the externalities of opioid use. The study concluded that "while the results here do not suggest that cannabis access laws are the only tool to address prescription opioid use, they do suggest hat cannabis laws could play a meaningful role in addressing the opioid epidemic. "
The study contributes to a mounting body of evidence regarding the effect which cannabis legalization has on drug overdose deaths, particularly those due to opioids. The conclusion is especially salient in a time when clandestine labs, mostly in China and Mexico but also in our borders, are flooding the streets with synthetic opioids and THC analogs. This flood of unregulated and extremely dangerous drugs has been directly tied to the fact that the government continues to implement draconian anti-drug laws that only exacerbate the problem.
As we discussed in our recent article on synthetic cannabinoids the war on drugs has created a sort of cat and mouse game, with new drug analogs appearing on the black market every time an old one is scheduled. We must admit that the half-trillion-dollar war on drugs has largely failed and that more people are dying of drugs today than ever before. Dramatic reform of drug policy in this country is necessary if we are going to finally start addressing the issue in a rational and mature way. Cannabis legalization is not the cure for this epidemic, but it is one way to reduce the burden that opioids are having on our society while simultaneously reducing the resource investments by our police and drug enforcement agencies, allowing them to focus on the drugs which truly are dangerous.
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