Pubdate: Thu, 07 Jul 2016
Source: Philadelphia Inquirer, The (PA)
Copyright: 2016 Philadelphia Newspapers Inc
Author: Don Sapatkin


Fewer Meds Are Sought in States With Legal Marijuana.

Patients fill significantly fewer prescriptions for such conditions 
as nausea and pain in states where medical marijuana is available, 
researchers reported Wednesday in one of the first studies to examine 
how medical cannabis might be affecting approved treatments.

Prescriptions for all drugs that treat pain combined, from cortisone 
to OxyContin, were nearly 6 percent lower in states with medical 
marijuana programs. Anxiety medication was 5 percent lower.

The result was a drop of more than $165 million in health-care 
spending in states that had medical marijuana programs running in 
2013, including New Jersey, according to the analysis of national 
Medicare data. The savings would equal 0.5 percent of the entire 
Medicare program's drug budget if medicinal cannabis were available 
in every state, the authors projected.

For years, lawmakers in state after state have approved medical 
marijuana programs - Pennsylvania acted two months ago - after pleas 
from desperate patients. The debates centered largely on the limited 
evidence of benefit and concerns about harm and abuse. There was 
little discussion of how medicinal cannabis would change treatments 
that patients were already receiving.

The new study, published Wednesday in the journal Health Affairs, is 
one of the first to hint at that effect.

"When states turned on a medical marijuana law," use of treatments 
approved by the Food and Drug Administration went down, said senior 
author David Bradford, a health economist at the University of 
Georgia, "suggesting that they were substituting something else - and 
the plausible thing that they would be substituting was marijuana."

Although the relationship may seem obvious, he and others made clear 
that the associated trends do not prove cause and effect. Nor can 
they suggest whether substitution would be a good thing or a bad thing overall.

If a patient stops going to his physician for, say, pain medication 
prescriptions because he's using marijuana instead, the doctor won't 
have a chance to possibly pick up on other medical issues, said 
Bradford, the university's public policy chair. Another example: 
"Let's say a patient comes to my office saying, 'I'm using marijuana 
to sleep because your drugs didn't work for me.' He tells me he is 
using marijuana because it really helps him sleep and his 
antidepressant isn't working - 'and by the way, I've flunked out of 
school,' " said J. Michael Bostwick, a psychiatrist at the Mayo 
Clinic in Rochester, Minn.

While there is some evidence that medical marijuana can be helpful 
for certain conditions, Bostwick said, "you may need to decide 
whether you want your degree or your drug, and that's not addressed" 
by the new study, which he nevertheless called "ingenious."

To measure the effect of medical marijuana programs, the researchers 
examined prescriptions filled in the Medicare Part D program in the 
17 states plus the District of Columbia that had legalized medicinal 
cannabis through 2013, compared with those that had not. They 
analyzed prescriptions for hundreds of drugs that can be used to 
treat nine conditions for which there is some evidence of benefit 
from marijuana. More than one condition may be present in some 
diseases, such as HIV.

For glaucoma and spasticity, the average number of daily doses 
prescribed by each physician was too small to determine a difference. 
But all the others were significantly lower in the states with 
medicinal cannabis: anxiety, depression, nausea, pain, psychosis, 
seizures, and sleep disorders.

By contrast, there was no difference for four classes of drugs that 
have no impact on conditions that may be treated by medical 
marijuana, such as blood-thinners and antibiotics.

The findings were no surprise to Peter Rosenfeld, 61, of 
Collingswood, who has struggled with a degenerative spine condition 
for decades. When New Jersey's medicinal cannabis program began three 
years ago, he tried 10 different strains before settling on one, 
known as Ghost OG.

About an eighth of an ounce a month, administered a few times a week 
through a vaporizer, reduces the spasticity, pain, and dizziness 
better than the prescription drugs that he used to take, said 
Rosenfeld, a retired aerospace researcher: "It is just a good balance 
of effectiveness and lack of side effects."

Gov. Wolf signed Pennsylvania's new program into law in April but it 
will not be operational for more than a year. Until it is, Luoann 
Speese has been getting three cannabinoids - CBD, THCA, and THC, each 
given orally in an oil - sent from different dispensaries in other 
states for her severely autistic 19-year-old daughter.

Diana Louann Stanley's seizures now last no more than a minute, down 
from 5 to 20 minutes, her mother said. "Now she is more aware of her 
surroundings. She has eye contact, which she never had before," said Speese.

Her daughter no longer needs two anti-epileptic medications, Banzel 
and Lamictal. And while the $150-a-month worth of cannabis has been 
provided largely by donations through her daughter's Facebook page, 
the cost is "a lot cheaper than pharmaceuticals," said Speese, who 
lives near Mechanicsburg.

The new study's estimates of Medicare cost savings from medicinal 
cannabis programs did not take account of out-of-pocket spending for 
the marijuana, which is not covered by insurance and is unlikely to 
be for a long time. Although 24 states plus Washington have passed 
programs, the substance remains illegal under federal law, with very 
limited availability for research.

Before it could be covered, classification as a narcotic would have 
to be changed, criminal penalties lifted, and various formulations 
would have to go through the same rigorous clinical trials that the 
FDA requires of prescription drugs; a single joint, for example 
contains at least 60 different cannabinoids. The current lack of 
evidence for effectiveness is due at least in part to the absence of 
randomized controlled trials.

With limited research but approval by nearly half the states, "we 
have kind of a big, poorly controlled natural experiment," said 
Brendan Saloner, an assistant professor of health policy and 
management at Johns Hopkins Bloomberg School of Public Health.

He called the new study "a good first step in establishing that 
substitution might be going on" but cautioned against using the 
findings to predict that medical marijuana was providing a net 
benefit. The Medicare prescription data by itself cannot indicate 
which patients were using medicinal cannabis and not using prescribed 
medication, Saloner said. It also does not show whether the patients 
were helped or harmed (or experiencing a placebo effect).

"It does, however, help us think about the intended medical 
consequences of medical marijuana laws," Saloner said.

Marijuana, for example, is sometimes considered a "gateway" to harder 
drugs, but as a pain reliever it may also be a substitute for 
powerful opioids. Saloner's own study, published two years ago in 
JAMA Internal Medicine, found that opioid overdose mortality rates 
were 25 percent lower in states with medical marijuana than in states without.

That study, like the new one, could not determine cause and effect. 
But Marina Goldman, a psychiatrist in private practice in Jenkintown 
and clinical associate at the University of Pennsylvania who has 
researched the addictive properties of marijuana, said she would not 
be surprised to find that some patients "may be afraid to go on 
opioids," especially because prescription painkillers "often are not 
fully effective."

Meanwhile, as more and more states approve medical - and recreational 
- - marijuana, many researchers worry, as Hopkins' Saloner put it, that 
the country is approaching "a tipping point culturally, politically, socially."

What if future research definitively shows that cannabis has no real 
medical benefit, he asked.

"You probably don't get it back in the bottle," Saloner said. Medical 
marijuana will be "very hard to walk back."
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MAP posted-by: Jay Bergstrom