CANNABIS AND THE GATEWAY DRUG THEORY: CORRELATION OR CAUSATION – WHERE DOES THE EVIDENCE POINT?
Whilst the Gateway Theory, may give us further pause in our public health policy making, it should not be the key driver of such policy formulation. The drug, in and of itself, has way too many other community diminishing issues that warrant it being kept out of the permission, let alone promotion space. But be rest assured, cannabis use will not lessen drug use engagement and the mounting harms these practices bring, so any action that creates, enables or expands a ‘gateway’ to self and community harm inducing drug use should be called out for what it is, in both policy and practice.
These results indicate that legal medical marijuana, particularly when available through retail dispensaries, is associated with higher opioid mortality. The results for recreational marijuana, while less reliable, also suggest that retail sales through dispensaries are associated with greater death rates relative to the counterfactual of no legal cannabis.
CONCLUSIONS:
Drivers who test positive for marijuana are significantly more likely to test positive for prescription opioids. Longitudinal studies with rigorous designs and toxicological testing data are needed to further address the substitution hypothesis between marijuana and prescription opioids.
Machine learning can accurately predict adults at risk for OUD, and identify interactions among the factors that pronounce this risk. Curbing early initiation of marijuana may be an effective prevention strategy against opioid addiction, especially in high risk groups.
But the lives of vulnerable people may be put at risk when science is distorted for corporate or ideological ends. As noted, several USstates responded to the much-hypedoriginal study of cannabis and opioid overdosesby authorizing the use of medical cannabis to treat heroin-addicted individuals. Advice that opioid users should use medical cannabis toreplace opioid agonist therapies (e.g., methadone, buprenorphine) poses significant risk because abrupt cessation of these medications dramatically increases the risks of an overdose death if users return to opioid use
DISCUSSION AND CONCLUSIONS:
Medical and non-medical cannabis use both were both associated with increased risks of prescription opioid misuse. Medical cannabis use, however, was not associated with prescription opioid use disorder, and non-medical cannabis was. There appeared to be differential associations between cannabis use and prescription opioid use disorder by cannabis use purpose.
Is the solution to the opioid epidemic as simple as the legalization of medical cannabis? Commenting on the Bachhuber et al. analysis (1), Finney et al. (4) cautioned that an ecological fallacy may be present—individuals using medical marijuana could have elevated overdose mortality rates even though there is a state-level reduction. They contended that a prospective study of individual pain patients was necessary to assess relationships between cannabis use, use of opioid medications, and other substance use (4).
In 2017 Colorado had a record number of opioid overdose deaths from any opioid, including heroin and Colorado has had a medical marijuana program since 2001.6
There are several reasons as to why any reported benefit will be outstripped by lack of benefit and increased risk of harm, and why cannabis is contributing to ongoing opioid use, and subsequently, the opioid epidemic.
There is evidence in animal models showing adolescent rats exposed to THC will develop enhanced heroin self administration as adults11 which may be due to activation of mesolimbic transmission of dopamine by a common mu opioid receptor mechanism.11,12
More than 90% of heroin users report a prior history of marijuana use compared to a prior history of painkiller use (47%).13
Prospective twin studies demonstrated that early cannabis use was associated with an increased risk of other drug abuse.14 This particular study was conducted when the THC content was much lower than todays products which can reach 95% THC.
Currently there is no widely available or accepted medical literature showing any benefit for pain with dispensary cannabis in common pain conditions.17
There is currently a large and growing body of evidence showing that cannabis use increases, rather than decreases non-medical prescription opioid use and opioid use disorder, based on followup of more than 33,000 people.19 Concurrent use of cannabis and opioids by patients with chronic pain appears to indicate a higher risk of opioid misuse.20 Closer monitoring for opioid-related aberrant behaviors is indicated in this group of patients and it suggests that cannabis use is a predictor of aberrant drug behaviors in patients receiving chronic opioid therapy.
There is sufficient and expanding evidence demonstrating that medical marijuana use will not curb the opioid epidemic. There is further evidence that marijuana is a companion drug rather than substitution drug and that marijuana use may be contributing to the opioid epidemic rather than improving it.
New research suggests that marijuana users may be more likely than nonusers to misuse prescription opioids and develop prescription opioid use disorder. The study was conducted by researchers at the National Institute on Drug Abuse (NIDA), part of the National Institutes of Health, and Columbia University.
The preliminary figures show that 959 people died in Colorado last year from drug poisoning, a figure that includes both intentional and unintentional overdoses. In 2016, 912 people died. In 2000, for comparison, drug poisonings claimed fewer than 400 lives.
Note: If you look at the blue bar you will see that opioid deaths have more than quadrupled since medical marijuana was legalized in Colorado (in 2000). And deaths rose from 377 in 2012 (year mj legalized) to 504 in 2016. No evidence that legal marijuana is helping in Colorado- if anything it could be contributing to making the opioid epidemic worse!
But the conclusion is not supported by data. This study and others that conclude marijuana helps fight the opioid crisis do not consider the many other strategies that have been implemented to fight opioid abuse, including the PDMP, treatment and Narcan. Nor is there any proof people are substituting marijuana for opioids. And this particular CO research (below) flies in the face of the actual data/ facts!
Opioid deaths in Colorado have increased based on the data from Colorado Public Health and Environment Dept.
I'm here to tell you this is not a safe drug," McCance-Katz said during a town hall event at "NatCon18," the National Council for Behavioral Health's annual conference.
"Americans have a right to know that and we should be telling them that," she continued.
And while tobacco and alcohol rates have declined among pregnant women in recent years, illicit drugs -- mainly marijuana but also opioids -- have increased from 78,000 women in 2015 to 111,000 in 2016, she said.
On the contrary, "marijuana use was associated with substantially increased risk of addiction and overdose for opioids," she said, citing research from Mark Olfson, MD, MPH, and colleagues in the American Journal of Psychiatry.
Conclusions: Our findings disconfirm the hypothesis that a population-level negative correlation between medical marijuana use and prescription drug harms occurs because medical marijuana users are less likely to use prescription drugs, either medically or nonmedically. Medical marijuana users should be a target population in efforts to combat nonmedical prescription drug use.
Marijuana use is associated with an increased risk of prescription opioid use.
Marijuana use seems to strengthen the relationship between pain and depression and anxiety, not ease it.
The overlapping endocannabinoid and endogenous opioid systems may explain this patient's response to therapy, and this synergistic relationship is discussed.
The endocannabinoid and endogenous opioid systems are syngergistic, which may explain the effect of naloxone in cannabis toxicity. Cannabinoid and opioid receptors belong to the rhodopsin subfamily of G-protein-coupled receptors which, when activated, reduce cellular levels of cyclic adenosine monophosphate (cAMP) by inhibiting adenylyl cyclase [8
Robledo P, Berrendero F, Ozaita A, et al. Advances in the field of cannabinoid–opioid cross-talk. Addict Biol. 2008;13:213–224. [Google Scholar]]. Both cannabinoid and opioid receptors are located primarily at presynaptic terminals, and their activation inhibits the release of several neurotransmitters. Opioid and cannabinoid receptor activation also modifies the permeability of sodium, potassium, and calcium channels [8Robledo P, Berrendero F, Ozaita A, et al. Advances in the field of cannabinoid–opioid cross-talk. Addict Biol. 2008;13:213–224. [Google Scholar]]. Receptors of both systems coexist in the central nervous system (CNS) with overlapping distribution in the brain, brainstem, and spinal cord [9Scavone JL, Sterling RC, Van Bockstaele EJ. Cannabinoid and opioid interactions: implications for opiate dependence and withdrawal. Neurosci. 2013;248:637–654. [Google Scholar]]. Cannabinoid and opioid receptors also co-localize in γ-Aminobutyric acid (GABA)ergic neurons with potential coupling to a second messenger systems and formation of heterodimers between the two receptors [11Pickel VM, Chan J, Kash TL, et al. Compartment-specific localization of cannabinoid 1 (CB1) and mu opioid receptors in rat nucleus accumbens. Neurosci. 2004;127:101–112. [Google Scholar]
].
We therefore must educate our youngsters, parents and educators before any use of marijuana or alcohol begins. We then must identify those individuals for whom marijuana or alcohol use has become problematic, getting them into an effective program of treatment before they progress to more dangerous alternatives.
Schools must revamp curriculums so children understand that any opioid misuse, be it prescription or street drugs, is a "red line" that they cannot cross.
The largest increases in opioid-related deaths in Florida from 2014 to 2015 were from the following drugs: Buprenorphine (up 102 percent), heroin (up 74 percent), fentanyl (up 69 percent), codeine (up 57 percent), and Oxymorphone (up 42 percent).
"We found no observational studies that met inclusion criteria, but a growing body of cross-sectional literature suggests negative opioid-related correlates among individuals who use cannabis and opioids concurrently. These include opioid misuse;9,10,99,133 a greater number of opioid refills;99 a longer duration of opioid use; a higher dose of opioid medication prescribed;9 and endorsement of using opioids and other pain medications without a prescription.134"
The Washington Poison Center (WAPC) saw a slight increase in calls regarding opioid exposures in 2016 (n=1,696) compared to 2015 (n=1,672). Of the calls received, over 70% (n=1,199) of the exposures occurred in individuals 20 years of age or older.
"Every time we destroy a field ... the locals come back to plant after our personnel has left the area," said Colonel Cipriano Cruz Quiroz, chief of staff of a special narcotics eradication unit based in Badiraguato, Sinaloa state.
Connection between legalization of marijuana and increase opioid addiction.
The effects of marijuana on the brain of an unborn child. Predisposing children for addiction. Here are the studies cited.
Furthermore, the study shows that people engaged in the non-medical use of prescription opioids rarely use heroin. Also, the transition to heroin for people abusing prescription opioids occurs at a lower rate than for others. The research indicates that the primary causes in the increase in heroin use and associated overdoses are lower market prices and higher purity for heroin.
"We found support for the synergistic effect on an individual level; people who tend to use more marijuana also tend to use more opioids," said Scott Novak, PhD, senior research scientist at RTI International, a leading research institute in Research Triangle Park, North Carolina.
What's worrisome is that the positive association between cannabis and opioid use is growing stronger. The study found that over time, people were using these drugs more often; there were more opioids days and more cannabis days.
Heroin use is part of a larger substance abuse problem.
Nearly all people who used heroin also used at least 1 other drug. Most used at least 3 other drugs.
Heroin is a highly addictive opioid drug with a high risk of overdose and death for users.
People who are addicted to…
Alcohol are 2 times more likely to become addicted to heroin. Marijuana are 3 times more likely to become addicted to heroin. Cocaine are 15 times more likely to become addicted to heroin.. Prescription opioid painkillers are 40 times more likely to become addicted to heroin. SOURCE: National Survey on Drug Use and Health (NSDUH), 2011-2013.
"Marijuana is the 800-pound gorilla in the room, when in fact, 295 Coloradans died two years ago of prescription drug overdoses," he notes.
In 2012, 36 drivers who tested positive for marijuana were involved in fatal car crashes, according the Colorado Department of Transportation. And 19-year-old Levy Thamba jumped to his death after consuming six times the recommended dose of a marijuana edible in April 2014
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