OPERATION LIGHTHOUSE

Currently 24 states - most recently Ohio on November 7, 2023 -and the District of Columbia have legalized recreational marijuana use. Medical use of marijuana is now legal in 39 states and D.C..Legalization has fuels a dramatic increase in use, particularly notable among young adults. Statistics from the National Institutes of Health (NIH) show marijuana use by adults aged 19-30reached an all-time high in 2021 with 43% reporting use in the past year, an increase from 34% in 2016. Daily use rose to 11% in 2021, i.e., more than one in ten young adults uses marijuana daily.

As cannabis use skyrockets, not surprisingly, so do cannabis-related traffic injury emergency room visits - by 223% in a recently reported Canadian study. Similarly, hospitalizations attributable to cannabis increased 1.6 times after legalization and commercialization of cannabis in Canada, primarily for cannabis-induced psychosis.

Perhaps before jumping into widespread legalization of marijuana for recreational use, it would be wise to carefully explore the risks of cannabis which are often understated and overlooked. A risk/benefit analysis, comparing the pros and cons of legalization is in order.

The opioid epidemic continues unabated with the CDC reporting more than 81,000 drug overdose deaths in the 12 months ending May 2020, about 70% opioid-related. Persons working in startup companies are typically among the most vulnerable demographic group with risk augmented by multiple additional stressors. Medication assisted treatment (MAT) is the gold standard for treatment of opioid use disorder. A study by Bolivar, et al in the current issue of JAMA Psychiatry reports that the addition of another treatment methodology - contingency management - significantly improves treatment adherence and duration of abstinence from opioids. Contingency management (CM) is an evidence-based behavioral intervention which provides patients with a material incentive - often a cash voucher - for showing evidence of meeting a therapeutic target, i.e., objective evidence of abstinence from opioids and/or methamphetamine. Commonly the incentive is increased at regular intervals with continued abstinence. The study was a systematic review of more than 10,000 patients in 74 studies evaluating the efficacy of CM in treating OUD with or without concurrent psychostimulant (methamphetamine) use. Notably, a recent report suggests that up to 30% of persons with OUD are also using a psychostimulant, usually methamphetamine. Unfortunately, concurrent psychostimulant use doubles the dropout rate for medication assisted treatment. Bolivar’s report found CM improved treatment outcomes in more than 70% of patients with either psychostimulant use or OUD as measured by abstinence and treatment adherence compared to MAT alone.

Bolivar, et al, suggest the evidence of efficacy for CM in OUD is so compelling that the Center for Medicaid and Medicare Health Services (CMS) should authorize the use of funds for CM treatment for OUD. They suggest that development and credentialing of CM treatment programs should be a federal public health priority.

New evidence just published in JAMA underlines the complexity of managing opioid use disorder (OUD) in persons taking long term higher dose opioids. The study reviewed medical and pharmacy records of more than 110,000 patients taking stable (at least 12 months), higher dose (at least 50 mg of morphine equivalent). Patients who underwent opioid tapering - defined as a 15% or higher reduction in dose - were noted to have a nearly 68% increase in emergency room or hospital visits for overdose events and a more than doubling of visits for mental health crises including depression, anxiety or suicide attempt.

There are sound medical indications for opioid tapering including the growing consensus that opioids lack efficacy for chronic pain. However, this study suggests tapering should be performed slowly - perhaps by 10% every 3 months - under careful clinician guidance with frequent follow-up. Stigmatized persons with OUD attempting self-taper are probably at even higher risk for overdose or mental health crisis. Employers should maintain lines of communication and check in frequently with employees dealing with SUD.

The CDC just released the most recent bulletin on drug overdose deaths in the U.S. reporting a nearly 30% increase above predicted numbers for the 12 months between December 2019 and December 2020. In three states, overdose deaths exceeded predictions by more than 50%. These devastating numbers are most likely driven by the impact of the pandemic as well as the huge influx of illegal fentanyl into the country.

The Top Ten: Worst Jurisdictions and Percentage above Predicted Overdose Deaths 

1. Vermont: 57.6%

2. Kentucky: 53.7%

3. South Carolina: 51.9%

4. West Virginia: 49.3%

5. Louisiana: 47.6%

6. California: 45.9%

7. Tennessee: 44.1%

8. Nebraska: 42.9%

9. Arkansas: 41.9%

10. District of Columbia: 39.2%

As a result, states such as SC are requiring prescribers to offer a prescription for naloxone, the emergency antidote for an opioid overdose,  to patients receiving certain doses of opioids.  It’s also mandated to offer a naloxone prescription to persons prescribed both an opioid and a benzodiazepine such as Ativan, Xanax, or Valium.

For more information, check out the CDC’s data on drug overdose’s.

Fewer than 20% of individuals with OUD in the U.S. receive these very effective medications. Most physicians learn very little about substance use disorders (SUD) in medical school. Even today, many practicing physicians are unaware that MAT is superior to treatment without drugs. A common misconception is that taking medications to manage the chronic illness of addiction is just replacing one addiction with another. Physicians prescribing MAT are required to obtain a special certification - the X waiver, further limiting access to this life saving treatment. The proposed “Mainstreaming Addiction Treatment Act” would eliminate the need for the X waiver and require an educational program of all providers renewing their DEA certificate (required for prescription of opioids and other controlled substances) with updated information on prevention and treatment of SUD.