Prescription Opioid Distribution after the Legalization of Recreational Marijuana in Colorado
Amalie K. Kropp Lopez, Stephanie D. Nichols, Daniel Y. Chung, Daniel E. Kaufman,
Kenneth L. McCall and Brian J. Piper
International Journal of Environmental Research and Public Health, 2020, 17, 3251
doi : 10.3390/ijerph17093251
There have been dynamic changes in prescription opioid use in the US but the state level policy factors contributing to these are incompletely understood. We examined the association between the legalization of recreational marijuana and prescription opioid distribution in Colorado. Utah and Maryland, two states that had not legalized recreational marijuana, were selected for comparison. Prescription data reported to the Drug Enforcement Administration for nine opioids used for pain (e.g., fentanyl, morphine, hydrocodone, hydromorphone, oxycodone, oxymorphone) and two primarily for opioid use disorder (OUD, methadone and buprenorphine) from 2007 to 2017 were evaluated. Analysis of the interval pre (2007–2012) versus post (2013–2017) marijuana legalization revealed statistically significant decreases for Colorado (P < 0.05) and Maryland (P < 0.01), but not Utah, for pain medications. There was a larger reduction from 2012 to 2017 in Colorado (–31.5%) than the other states (–14.2% to –23.5%). Colorado had a significantly greater decrease in codeine and oxymorphone than the comparison states. The most prevalent opioids by morphine equivalents were oxycodone and methadone. Due to rapid and pronounced changes in prescription opioid distribution over the past decade, additional study with more states is needed to determine whether cannabis policy was associated with reductions in opioids used for chronic pain.
Keywords : cannabis; fentanyl; Maryland; morphine; oxycodone; opiate; public policy; Utah
The US opioid epidemic stems from the early 1990s when the medical community recognized pain as a fifth vital sign . Opioids increased from 148 million prescriptions in 2005 to over 206 million by 2011 . Analysis of the Drug Enforcement Administration’s (DEA) comprehensive dataset identified a marked increase in the total volume of opioids prescribed each year, with a national peak in 2011  followed by declines in most agents  with the exception of buprenorphine . Use, and misuse, of opioids has not homogeneously impacted the US. There was a moderate (r = 0.49) correlation between a state’s median age and per capita prescription opioid use . Analysis of the National Health and Nutrition Examination Survey estimated that one-seventh of prescription opioid use was attributable to obesity and associated conditions . States with fewer uninsured people as a result of Medicaid expansion had greater prescription opioid use [7,8]. Use of the OUD pharmacotherapy buprenorphine diered over twenty-fold between the highest (Rhode Island = 2158 morphine mg equivalents (MME) / person) and lowest (North Dakota = 99 MME/person) states . In contrast, use of the high potency prescription opioid fentanyl only showed three-fold state dierences . The rate of opioid overdoses among Hispanic people was half that of white people .
Healthcare providers have the responsibility to treat their patient’s non-cancer pain while also considering nonopioid alternatives. Since California first legalized medical marijuana in 1996, 33 states and the District of Columbia have passed laws broadly legalizing marijuana, either medically or recreationally. As of June 2019, Washington D.C. and ten other states have expanded to condoning recreational marijuana use . With the endorsement of the states, more objective evidence is beginning to emerge that marijuana may be of value to manage chronic pain , reduce overdose mortality [12,13], treat opioid withdrawal , or decrease opioid prescribing [14–18]. Marijuana has a much lower risk of addiction and virtually no overdose danger relative to opioids [19–23]. In January 2017, the National Academies of Sciences, Engineering and Medicine released a peer-reviewed, comprehensive review showing “conclusive evidence” that cannabinoids can be used safely and eectively to treat chronic pain . However, the evidence base was too limited to make a determination regarding whether marijuana could be used to treat addiction to other drugs . Over-three fifths (62%) of Americans are supportive of legalized marijuana for medical purposes, which has doubled from 31% in 2000 . The popularity of marijuana is quickly rising in the fifty years and older population . This demographic may be most likely to experience chronic pain-related conditions and are receptive to the analgesic properties of marijuana .
To date, there has been little research  conducted on the eects of adult-use marijuana laws on opioid distribution. In November 2000, Colorado voters approved Amendment 20, implementing the legalization of medical marijuana. Twelve years later, Colorado approved Amendment 64, legalizing adult-use or recreational marijuana . By January 2014, dispensaries were opened to the public . This report compares medical opioid distribution in Colorado with two states, Utah and Maryland, which had not legalized recreational marijuana. Although the primary emphasis was on opioids used for pain, a secondary objective was to describe prescription opioid use more broadly in these states including those used for OUD treatment.