Author Insights: Legalizing Medical Marijuana May Reduce Opioid Deaths

Marcus A. Bachhuber, MD, a Robert Wood Johnson Foundation Clinical Scholar at the Philadelphia Veterans Affairs Medical Center, and colleagues found that states that legalize marijuana experience lower rates of opioid deaths, on average, compared with states that don’t allow medical marijuana. Image: University of Pennsylvania

Marcus A. Bachhuber, MD, a Robert Wood Johnson Foundation Clinical Scholar at the Philadelphia Veterans Affairs Medical Center, and colleagues found that states that legalize marijuana experience lower rates of opioid deaths, on average, compared with states that don’t allow medical marijuana. Image: University of Pennsylvania

Opioid-overdose deaths increased in states across the country between 1999 and 2010, but states that legalized medical marijuana saw less-steep increases than those without, according to a study published in JAMA Internal Medicine this week.

Growing use of prescription opioids over the past 2 decades to treat chronic pain has helped drive increasing rates of opioid overdoses. To help reduce the problem, state and federal governments have instituted prescription monitoring programs and drug safety plans and tightened restrictions on prescribing popular opioids. Some of these efforts have yielded reductions in opioid overdoses on a state level, but national rates continue to rise.

At the same time, a growing number of states have legalized medical marijuana. In states like Colorado, where medical marijuana has been legal since 2000, the primary reason for a physician to recommend medical marijuana is pain. Some of the other indications for prescribing medical marijuana include nausea from cancer chemotherapy and poor appetite and accompanying weight loss resulting from a chronic illness such as HIV infection.

Marcus A. Bachhuber, MD, a Robert Wood Johnson Foundation Clinical Scholar at the Philadelphia Veterans Affairs Medical Center, and his colleagues analyzed opioid overdose rates in states with or without legalized medical marijuana to see whether its availability to treat pain helps reduce opioid deaths. They found that while opioid overdose deaths have continued to increase in all states, states that permit prescribing medical marijuana had lower rates of opioid overdose deaths compared with those that do not.

Bachhuber discussed his results with news@JAMA.

news@JAMA: Why did you decide to do the study?

Dr Bachhuber: I’m a primary care physician and I’ve talked to many patients with chronic pain. In the past, I’ve had patients who said they’ve tried prescription opioid painkillers but the only thing that worked to reduce their pain was marijuana. So, my colleagues and I wondered whether people might be choosing to treat their pain with marijuana in states where this is legal, and if these states might see lower rates of painkiller overdoses or deaths.

news@JAMA: You found that the rates of opioid overdose were lower in states allowing medical marijuana. Can you explain what that means?

Dr Bachhuber: We found that rates of opioid overdose deaths have increased in all states. But in the years after the legalization of medical marijuana, states that did so had a rate that was 25% lower than what we’d expect to see in that state, given past trends and what was going on in the rest of the country.

news@JAMA: Why might making medical cannabis available reduce opioid overdose rates?

Dr Bachhuber: Going into the study, we hypothesized that patients with chronic pain might replace opioids with medical marijuana or supplement opioid medications with medical marijuana, allowing them to reduce their opioid dose. Alternatively, there is still a debate about whether medical marijuana might lead patients to use other drugs, so rates of opioid overdose might have increased. We thought there could be a change in either direction, and that’s why we decided to study it.

news@JAMA: Your study can’t prove that medical marijuana was the factor that reduced opioid overdoses. Might there be other explanations?

Dr Bachhuber: One of the limitations of our study is that we can’t identify, measure, and control for every factor that was different between the states and might be contributing to our results. If broader changes were happening in states that also implemented medical marijuana laws, such as changes in patterns of pain treatment or illicit drug use, those could be influencing our results and have nothing to do with medical marijuana. But, if medical marijuana laws are in fact reducing opioid overdose deaths, we would need studies following individuals over time to see how exactly these laws are shifting behavior.

news@JAMA: How much do we know about the use of opioids or marijuana for pain treatment?

Dr Bachhuber: Opioids are approved by the FDA for the treatment of pain; they have undergone randomized trials, but there is very little evidence for long-term use for more than a few months. Marijuana is still considered a Schedule I drug, meaning the FDA says there is no valid medical use. Because of this, there is not much research out there to help us understand the risks and benefits of medical marijuana, including what conditions could be successfully treated, which patients might benefit the most, and what the risks may be. Also, head-to-head studies of marijuana and opioids would be incredibly useful for clinical practice.

news@JAMA: What is the main take-home message from your study?

Dr Bachhuber: Our study provides evidence of a possible unexpected public health benefit of medical marijuana legalization. Medical marijuana may have other possible impacts on public health, and as more states enact these laws, it will be worth continuing to look at this issue.

Author Insights: Women a Growing Political Force in Medicine

David J. Rothman, PhD, of Columbia University, and colleagues found that physicians’ political allegiances are shifting as more women enter the profession. Image: Columbia University

David J. Rothman, PhD, of Columbia University, and colleagues found that physicians’ political allegiances are shifting as more women enter the profession. Image: Columbia University

Despite the common assumption that politically speaking, US physicians lean Republican, growing ranks of women in the profession are shifting the profession’s political leanings toward the left, according to research published in JAMA Internal Medicine this week.

Women as a voting block have long favored the Democratic Party, but political parties and political observers are increasingly recognizing the power women have to swing elections, noted one of the study’s coauthors David J. Rothman, PhD. Rothman, professor of social medicine at Columbia University in New York City, cited a recent New York Times article on the growing political power of single women. Women account for roughly one-third of the US physician workforce, and that proportion will grow, given the nearly equal numbers of men and women entering medical school. Although many have speculated how this trend would change the way medicine is practiced, Rothman and his colleagues were surprised to find the growing ranks of women in medicine are also shifting the profession’s political allegiances.

The new study involved an analysis of donations from physicians to national political campaigns between the 1991-1992 election cycle through the 2011-2012 election cycle. They found that physician campaign contributions increased during this period from $20 million to $189 million and that the percentage of physicians contributing to national campaigns increased from 2.6% to 9.4%. Physician contributions to Republicans declined between the mid-1990s and the 2007-2008 election cycle, with fewer than half of physicians who made contributions backing Republicans in the 2007-2008 cycle. Republican contributions by physicians recovered in the 2009-2010 cycle, but dipped back down to about 50% in 2011-2012. Although the majority of male physician contributors still back Republicans, only 31% of female physician contributors supported that party.

Rothman discussed the findings with news@JAMA:

news@JAMA: Why did you decide to do this study?

Dr Rothman: I founded the Institute on Medicine as a Profession and we offer a 2-year fellowship to encourage physicians to become active as advocates. I invited Howard Rosenthal, PhD, who has studied political polarization in the United States at New York University to talk with the fellows. He and his colleagues have quantified every vote in Congress from 1789 to the present to see how much overlap there was in the voting of Republicans and Democrats. They found that Congressional voting has never in history been as polarized as it is now. After his talk, we went to dinner with the fellows and the question came up: “Wouldn’t it be interesting to see how physicians’ political leanings have changed as a cohort?”

Ours is among the first studies on physicians’ political behavior. There have been a few studies on physicians’ political preferences and some studies on the lobbying behavior of the American Medical Association and other physician groups.

news@JAMA: Do you think the public’s perceptions differ from what you found?

Dr Rothman: It’s not clear to me. Patients don’t ask their physicians about politics, and physicians don’t ask their patients about politics. Most patients know that physicians are high earners, so they would likely put physicians on the right end of spectrum. Some may remember fierce opposition to Medicare by the AMA. The fact that most physicians backed the Affordable Care Act may not register.

We show that perception was Right 25 years ago; physicians used to mostly contribute to Republicans. But now, contributions to Democrats are on the upswing.

news@JAMA: What do you think is driving the shift?

Dr Rothman: The first thing driving it is women, as they become more prominent in the profession. Women are more likely to vote Democratic and contribute to Democrats. The second thing is the growing number of salaried physicians at not-for-profit institutions. The third element is specialty. Very high earners, those with surgeon in their title, are very much on the Republican wing, but when it comes to pediatricians, psychiatrists, and internists, income drops and political allegiances shift to the left.

There are some interesting twists. Women surgeons trend Republican, but are more likely to support Democrats than male surgeons. Pathologists are right in the middle.

news@JAMA: What is the most important take-home message of the study?

Dr Rothman: Our results suggest physicians as a group are in play; don’t take it for granted that they are Republican. Those seeking political victory should count them as open to persuasion. The second big take-home message is that there are now 20 physicians in Congress, and 16 are Republicans. They are older and mostly guys, but that is going to change.

Not only are physicians in play as a group. I think we will see more physicians go into politics. Parties should be engaged with physicians and physicians are going to be engaged with parties.

Author Insights: Physicians More Likely Than the Public to Register as Organ Donors

Alvin Ho-ting Li, BHSc, of Western University in Ontario, Canada, and colleagues, found that physicians are more likely to register as organ donors than the general public. Image: Western University

Alvin Ho-ting Li, BHSc, of Western University in Ontario, Canada, and colleagues, found that physicians are more likely to register as organ donors than the general public. Image: Western University

Physicians are almost 50% more likely to register as an organ donor than other citizens, suggests a Canadian study published today in JAMA. The findings indicate that physicians may have a higher level of confidence than the public in being an organ donor.

Despite waiting lists for organs in many countries, the percentage of individuals registered in national organ donation registries in most countries is below 40%. The United States fares a bit better than average, with 48% of adults registered as organ donors. Registries provide information to clinicians about a patient’s wishes regarding organ donation, which reduces confusion for families in the case of an unexpected death.

Boosting donor registrations could help reduce the number of patients on waiting lists for an organ transplant. But not everyone is comfortable with organ donation. Some people have religious concerns or worry that being a donor will negatively affect the medical care they receive. Concerns about organ donation have led to lower-than-average rates of registration in Ontario, Canada, where only about 25% of adults have registered. Currently, there are more than 1500 people on transplant waiting lists in Ontario.

To help assuage some concerns, Alvin Ho-ting Li, BHSc, a PhD candidate at Western University in Ontario, Canada, compared physicians’ rate of registration in Ontario’s organ donor registry with the rate of registration among matched nonphysician controls. The registration status of more than 15 000 physicians and more than 60 000 matched controls were compared.

Li and his colleagues found that 6596 or 43.3% of the physicians were registered as organ donors compared with 29.5% (17 975) of the matched controls. Women physicians, younger physicians, and physicians living in rural communities were more likely to donate than other groups. Certain medical specialties also had higher-than-average organ donation rates, including emergency medicine, internal medicine, pediatrics, or psychiatry.

Li discussed the findings with news@JAMA:

news@JAMA: Why did you decide to do this study?

Li: A common myth that deters people from becoming an organ donor is that physicians won’t try as hard to treat you if you sign up to become a donor. We thought that one way to combat that myth is to show that physicians are more willing to register themselves.

news@JAMA: What are other factors that discourage donor registration?

Li: There are a lot of factors. One of biggest is lack of knowledge about the existence of the local registry. Some individuals think carrying a donor card is enough, and they don’t know a database exists. It is important to register your decision to donate so that it can be made available to the right people at the right time and shared with your loved ones.
There may be cultural concerns and other myths about organ donation that also deter people from registering.

news@JAMA: Why do you think Ontario physicians are more likely to register than the public?

Li: Physicians may be more aware of the importance of donation and organ transplants. Hopefully, they are more supportive as well. They should be encouraging more people to donate and lead from the front.

news@JAMA: What do you think can be done to increase the public’s comfort level with organ donation?

Li: One of the most important steps is to further raise awareness of the importance of registering as an organ donor. It’s also important to make sure people know where and how to register and how important organ donation is to many people who need a transplant.

Many people are supportive, but haven’t taken action to register nor have talked to their family members about their desire to donate. There are many myths about organ donation that need to be addressed. For example, some people worry they will not able to have open casket if they agree to donate. Others worry they are too old or not in good enough health to become an organ donor. None of the these are true.

Nontoxic Doses of Party Drug Ecstasy Become Fatal in Warm Conditions

An animal study suggests that using MDMA under social conditions in warm environments may amplify its effect on body temperature. Image: © iStock.com/passigatti

Environmental conditions in settings where the illicit drug ecstasy is commonly used may exacerbate adverse effects of the drug. Image: © iStock.com/passigatti

A combination of warmer ambient temperatures and social interaction may cause normally nontoxic doses of the recreational drug commonly known as ecstasy or Molly to become fatal, suggests findings from an animal study. The study, published today in the Journal of Neuroscience, may help explain how the drug, 3,4-methylenedioxy-N-methylamphetamine (MDMA), causes fatal hyperthermia in some individuals and suggests strategies for treating this serious adverse effect.

A party drug at clubs and impromptu warehouse parties, MDMA has a reputation among users as being safer than other illicit drugs. The drug triggers feelings of euphoria and friendliness. It is responsible for fewer emergency department visits than other illicit substances, including marijuana, and is being studied as a potential treatment for posttraumatic stress disorder and anxiety.

However, the drug has been linked to fatal cases of heat stroke, and previous studies had suggested that consuming the drug under the hot temperatures often found in party settings may exacerbate the drug’s effect on body temperature.

The latest study suggests that elevated room temperatures combined with social interactions may turn nontoxic doses of the drug into fatal ones. Researchers from the National Institute on Drug Abuse implanted heat sensors in the brain, muscle tissue, and skin of rats and gave the animals a moderate dose of MDMA comparable with doses used recreationally. The researchers found that at normal room temperatures, the brain temperatures of animals given the nontoxic doses of MDMA showed very little effect but deleterious effects dramatically increased when the animals were exposed to temperatures exceeding 80 degrees Fahrenheit. Rats given the usually nontoxic MDMA dose died within 6 hours in a warm environment.

The researchers found that increased narrowing of the blood vessels, which prevented  efficient heat loss, likely played a role in exaggerating the drug’s effects.

The researchers argue that the environmental conditions under which MDMA is used recreationally may dangerously exacerbate its effects on body temperature. According to the authors, the findings also suggest that medical interventions aimed at reducing constriction of the blood vessels may help to counteract MDMA-induced heat stroke.

Author Insight: Patients Who’ve Had Certain Life-Threatening Systemic and Skin Reactions at Risk of Recurrence

Yaron Finkelstein, MD, of the Hospital for Sick Children in Toronto, and colleagues, found that patients who experience Stevens-Johnson syndrome or toxic epidermal necrolysis are at risk of a recurrence. Image: Hospital for Sick Children

Yaron Finkelstein, MD, of the Hospital for Sick Children in Toronto, and colleagues, found that patients who experience Stevens-Johnson syndrome or toxic epidermal necrolysis are at risk of a recurrence. Image: Hospital for Sick Children

Patients who develop certain life-threatening skin reactions, Stevens-Johnson syndrome or toxic epidermal necrolysis (TEN), are at risk of a recurrence, suggests a study published today in JAMA.

Stevens-Johnson syndrome and TEN are rare adverse events, occurring in just 1 to 7 individuals per million population each year. Three-quarters of these life-threatening reactions are triggered by medications and one-quarter by infections. Patients initially develop fever and skin lesions, progressing to lose skin. About 20% of patients who develop these conditions die. Those who survive may face long-term complications, such as severe scarring or organ damage.

Yaron Finkelstein, MD, of the Hospital for Sick Children in Toronto, and colleagues analyzed data on all the individuals hospitalized in Ontario with one of these systemic and skin reactions between April 2002 and March 2011. They identified 708 patients hospitalized for Stevens-Johnson Syndrome or TEN, nearly 18% of them children or adolescents. More than one-quarter of the patients were admitted to a burn unit or critical care unit and 17.9% died in the hospital or within 60 days of discharge. They found that 7.2% of these patients experienced a recurrence through 2012, suggesting that the risk of another severe adverse reaction is markedly elevated in this group.

Dr Finkelstein discussed the findings with news@JAMA:

news@JAMA: Why did you decide to do this study?

Dr Finkelstein: It stems from a pilot study published in 2011 where we examined the recurrence of Stevens-Johnson syndrome in 55 children. That study found an unexpectedly high rate of recurrence. These conditions are uncommon but are potentially fatal, therefore, it was very important conduct a larger, population-based study.

news@JAMA: Were you surprised to find an elevated rate of recurrence?

Dr Finkelstein: I expected something in that range because of the pilot study. But from the medical communities’ perspective, this was unexpected. These are really uncommon adverse events, occurring in only 1 to 7 individuals out of 1 million population. The rate of recurrence we found is several thousand times higher than what we would expect in the general population, if the episodes were unrelated.

news@JAMA: Is there a mechanism that would explain the high recurrence rate?

Dr Finkelstein: The pathophysiological mechanism is not entirely elucidated, but we know some patients are genetically predisposed to develop these conditions. Presently, there are about 15 genetic mutations that are known to predispose an individual to these conditions. Some are linked to certain ethnic backgrounds. There are likely many other mutations we are not aware of yet.

news@JAMA: What are the implications of these findings for the care of patients who’ve experienced such a reaction?

Dr Finkelstein: The main message is for physicians to advocate for these patients. These conditions carry a 20% short-term mortality rate and a high rate of long-term complications. Clinicians who care for a patient who has survived one of these reactions should use discretion and extra caution when prescribing future medications. This is especially true for medications commonly associated with these adverse events, including certain antiepileptics, certain antibiotics, and the gout medication allopurinol.

news@JAMA: Do you plan additional studies?

Dr Finkelstein: We plan to look at elucidating additional genetic mutations as well as explore long-term complications and the quality of life of survivors. There is some evidence many suffer prolonged trauma. In our study, 7% of the cohort died within 60 days after discharge.

Our main goal is to raise awareness about this phenomenon of recurrence and emphasized the need to weigh the risks and benefits of future drug therapy in patients surviving these potentially fatal conditions.

Study Links Sleep Deprivation With Obesity in Children

A new study raises the possibility that chronic sleep deprivation during infancy and early childhood may contribute to children being overweight or obese. Image: © iStock.com/Marcin Poziemski

A new study raises the possibility that chronic sleep deprivation during infancy and early childhood may contribute to children being overweight or obese. Image: © iStock.com/Marcin Poziemski

Children who get less sleep in infancy and early childhood may be at greater risk of being overweight or obese during mid-childhood, according to a study published today in the journal Pediatrics.

Over the past 20 years, studies have documented that the amount of daily time spent sleeping has declined for infants, children, and adolescents. Cultural changes have likely contributed to this trend, including more 2-parent working families and longer work hours. There is some evidence that reduced duration of sleep can to contribute to negative health outcomes, such as increased risk factors for cardiovascular disease.

Elsie M. Taveras, MD, MPH, of Massachusetts General Hospital for Children, and colleagues examined whether infants and young children who slept less than their counterparts were more likely to be overweight or obese in mid-childhood. They asked the mothers of 1046 children about how long their child slept in a typical 24-hour period at 6 months, and then their daily sleep duration for each year between ages 1 year and 7 years.

Overall, 75% of the children were in the normal weight range, 13.8% were overweight, and 11% were obese, based on body mass index (BMI). But compared with children who routinely slept the longest, children in the group with the least sleep were significantly more likely to be overweight or obese: 55.3% had a BMI in the normal range, 10.7% were overweight, and 34% were obese. Children who got the most sleep were the least likely of any group to be obese: 81.7% had a BMI in the normal range, 11.5% were overweight, and 6.8% were obese. The researchers found a similar association when they looked at other measures of weight, including trunk fat and waist-to-hip circumference.

The authors noted that the study has some limitations, including its reliance on parental reports and underrepresentation of Hispanic children. Because the findings are observational, the study cannot prove that sleep deprivation causes weight gain in children. In addition, factors related to lack of sleep that were not controlled for in the statistical analyses may explain the relationship.

The authors propose various mechanisms that might explain how chronic sleep deprivation could contribute to weight gain. For example, lack of sleep may make children feel hungrier and less full. Sleep deprivation may also affect levels of hormones that have been linked to abdominal obesity, such as cortisol, or may upset the body’s circadian clock and gene expression.

Regardless of the exact mechanism, the study suggests that understanding the factors that contribute to reduced sleep in children and helping parents facilitate longer sleep durations for children may help reduce obesity and overweight in children.

Report: To Cut US Health Spending, Spur Development of Cost-Saving Interventions

Promoting the development of more cost-effective therapies will help cut US health spending, according to a RAND report. Image: © iStock.com/BrianAJackson

Promoting the development of more cost-effective therapies will help cut US health spending, according to a RAND report. Image: © iStock.com/BrianAJackson

Funders, policy makers, and others should work to spur the development of cost-saving therapies that would help rein in US health spending, recommends a new report from RAND.

Spending on expensive new technologies and treatments is one of the factors driving US health costs—more per capita than any other nations—and leaving individuals and families feeling the pinch of rising copays and other health-related expenses, according to the report. Curbing these costs has been identified as key to maintaining the nation’s financial health.

Most cost-cutting strategies focus on reducing use of expensive treatments that don’t add much value, but the new report says that efforts to restrain costs need to start early in the development of new treatments.

The United States spends more than $2 trillion a year on health care “and the financial incentives for innovators, investors, physicians, hospitals, and patients often lead to decisions that increase spending with little payback in terms of health improvement,” explained the study’s lead author Steven Garber, PhD, MS, in a statement.

Garber, a senior economist at RAND, and his coauthors suggest that policy tweaks are needed to create financial incentives for developing interventions that both promote health and reduce health spending. The US government might consider offering prizes for interventions that cut costs or expedite US Food and Drug Administration approvals for such products, or investing in cost-saving interventions by purchasing their patents or creating public-private investment funds, they suggest.

They also suggest changes to the Centers for Medicare and Medicaid Services (CMS) reimbursement policies to promote use of more cost-effective interventions. For example, they suggest CMS work with the FDA to coordinate policies on approvals and coverage, and reform coverage policies to promote use of cost-saving treatments and discourage use of costly treatments that don’t improve care.

Garber and colleagues argue in the report that “spending on health care in the United States constrains our opportunities to make progress on major public and private priorities other than health, and there is substantial room for reducing spending in ways requiring only fairly small sacrifices in population health.”