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the question below is based on the article titled: Cannabis Use and Risk of Prescription Opioid Use Disorder in the United States Mark Olfson, M.

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Cannabis Use and Risk of Prescription Opioid Use

Disorder in the United States

Mark Olfson, M.D., M.P.H., Melanie M. Wall, Ph.D., Shang-Min Liu, M.S., Carlos Blanco, M.D., Ph.D.

Objective: The authors sought to determine whether cannabis

use is associated with a change in the risk of incident

nonmedical prescription opioid use and opioid use disorder

at 3-year follow-up.

Method: The authors used logistic regression models to

assess prospective associations between cannabis use at

wave 1 (2001-2002) and nonmedical prescription opioid use

and prescription opioid use disorder at wave 2 (2004-2005)

of the National Epidemiologic Survey on Alcohol and Related

Conditions. Corresponding analyses were performed among

adults with moderate or more severe pain and with nonmedical

opioid use at wave 1. Cannabis and prescription

opioid use weremeasured with a structured interview (the

Alcohol Use Disorder and Associated Disabilities Interview

Schedule-DSM-IV version). Other covariates included age,

sex, race/ethnicity, anxiety ormooddisorders, family history

of drug, alcohol, and behavioral problems, and, in opioid use

disorder analyses, nonmedical opioid use.

Results: In logistic regression models, cannabis use at wave 1

was associatedwith increased incident nonmedical prescription

opioid use (odds ratio=5.78, 95% CI=4.23-7.90) and opioid

use disorder (odds ratio=7.76, 95% CI=4.95-12.16) at wave 2.

These associations remained significant after adjustment for

background characteristics (nonmedical opioid use: adjusted

odds ratio=2.62, 95% CI=1.86-3.69; opioid use disorder:

adjusted odds ratio=2.18, 95% CI=1.14-4.14). Among

adults with pain at wave 1, cannabis use was also associated

with increased incident nonmedical opioid use (adjusted

odds ratio=2.99, 95% CI=1.63-5.47) at wave 2; it was also

associated with increased incident prescription opioid use

disorder, although the association fell short of significance

(adjusted odds ratio=2.14, 95% CI=0.95-4.83). Among adults

with nonmedical opioid use atwave 1, cannabis use was also

associated with an increase in nonmedical opioid use (adjusted

odds ratio=3.13, 95% CI=1.19-8.23).

Conclusions: Cannabis use appears to increase rather than

decrease the risk of developing nonmedical prescription

opioid use and opioid use disorder.

Am J Psychiatry 2018; 175:47-53; doi: 10.1176/appi.ajp.2017.17040413

After more than two decades of increasing prevalence of

prescription opioid use disorder in the United States (1, 2), the

number of people in the U.S. population with prescription

opioid use disorders reached 2 million in 2015 (3). Rising rates

of prescription opioid use disorder have coincided with the

largestepidemicofopioidoverdosedeaths inU.S.history. In2015,

unintentional drug overdose deaths, most of which involved

opioids, claimed over 47,000 lives (4). The crisis in nonmedical

use of prescription opioids, which has exacted a heavy burden

not only on individuals but also on their families and communities,

has prompted federal policy makers to consider prescription

opioid use disorder a threat to public health (5).

In the wake of rising rates of nonmedical prescription

opioid use, there has been increased public (6) and professional

(7) interest in the possibility that cannabis might

help to curb or prevent opioid use disorder. Support comes

from two widely publicized ecological analyses indicating

that compared with states that do not permit medical marijuana,

annual death rates due to opioid overdoseswere nearly

one-quarter lower in states that do permit medical marijuana

(8, 9). Significant reductions in opioid prescribing have also

been reported following passage of medical marijuana laws

(10). Such ecologic analyses, however, provide no information

on whether individual patientswho use cannabis have a lower

or higher risk of developing opioid use disorders (11).

The possibility that cannabis lowers the risk of opioidrelatedmorbidity

has fueled speculation concerning potential

mechanisms.Aleading hypothesis is that cannabis use tends

to lower opioid use and risk of opioid use disorder through

increased control of pain (8, 12). A recent meta-analysis of

randomized controlled trials provides a moderate level of evidence

that cannabinoids improve some forms of chronic pain

(13).AlargeDutch study reported that just over half of adults in

registered cannabis programs also received prescriptions for

See related features: Editorial by Dr. McCarty (p. 6), Clinical Guidance (Table of Contents), and AJP Audio (online)

Am J Psychiatry 175:1, January 2018 ajp.psychiatryonline.org 47

ARTICLES

pain medications, suggesting thatmedical marijuana is frequently

used for pain control (14). In a small, uncontrolled cross-sectional

survey of medical marijuana users with chronic pain recruited

from a cannabis dispensary, cannabis use was associated with a

64%decline inopioiduse (N=118) (12). Cannabis exposurehas also

been associated with increased analgesia among opioid-treated

patients with chronic pain (15), suggesting that cannabis may

potentiate antinociceptive effects of opioids, permitting lower and

presumably safer opioid dosing to achieve comparable analgesia.

Much remains to be learned about the association between

cannabis use and nonmedical prescription opioid use

or opioid use disorders. No prospective epidemiological or

clinical studies have demonstrated that cannabis use reduces

use of opioids. Moreover, epidemiologic research suggests

that cannabis may actually increase the risk of other drug

use disorders, including opioids. A retrospective Australian

twin study reported that early initiation of cannabis use

was associated with increased risks of other drug use and

abuse/dependence, including opioid use and opioid abuse/

dependence (16). Prospective epidemiological research furthersuggests

thatcannabisuse isa risk factor forotherdruguse

disorders (17).However, prospective epidemiological research

has not previously examined the specific association between

cannabis use and nonmedical prescription opioid use or opioid

use disorder to inform clinical practice and policy.

We sought to address this critical gap in knowledge with

prospective data from the National Epidemiological Survey

on Alcohol and Related Conditions (NESARC), a large, nationally

representative sample. We examined the association

between cannabis use and incident nonmedical prescription

opioid use and disorder 3 years later, after adjusting for several

relevant demographic and clinical covariates. We also evaluated

whether cannabis use among adults with nonmedical

prescription opioid use was associated with a subsequent

decrease in nonmedical opioid use.

METHOD

Sample

The 2001-2002 NESARC (wave 1), and the 2004-2005 followup

(wave 2) is a nationally representative sample of the noninstitutionalized

adult U.S. population conducted by the U.S.

Census Bureau under the direction of the National Institute on

Alcoholism and Alcohol Abuse (18, 19). The response rate for

wave 1 was 81.0%. Excluding ineligible respondents (e.g., those

who were deceased), the wave 2 response rate was 86.7%, resulting

in a cumulative response rate of 70.2%(N=34,653). Wave

2 NESARC weights include adjustments for nonresponse, demographic

factors, and psychiatric diagnoses to ensure that the

wave 2 sample approximated the target population, which was

the original sample minus attrition between the two waves (18).

Assessment

All diagnoses were made according to DSM-IV criteria,

using the AlcoholUse Disorder andAssociated Disabilities

Interview Schedule-DSM-IV version (AUDADIS-IV) for

waves 1 and 2 (20). Consistent with previous reports,

nonmedical use of a prescription opioid was defined as using

a prescription analgesic "without a prescription, in greater

amounts,more often, or longer than prescribed, or for a reason

other than a doctor said you should use them" during the

12 months preceding the interview. More than 30 symptom items

were used by the AUDADIS-IV to define 12-month prescription

opioid use disorder according toDSM-IV criteria. TheNESARC

also collected information for other substance use disorders

(nicotine dependence, alcohol use disorder, and drug use disorders,

including other prescription drug use disorders). The

reliability of theAUDADIS-IVprescription opioid use questions

(kappa=0.66) and associated substance use disorder diagnoses

(kappa=0.53-0.84) are well documented in several psychometric

studies, including in clinical (20) andgeneralpopulation

(21) samples. Further concurrent and predictive validity of

the prescription opioid use disorder diagnosis has been

documented by increased risk of related psychopathology,

impairment, and probability of seeking treatment (22).

Thefrequency of past-year cannabis usewas assessed with

an 11-level item ranging from no use in the past 12 months to

use every day in the past 12 months. Cannabis use was collapsed

into a four-level variable including no use in the past

last 12 months, occasional use (at least once a year but less

than once a month), frequent use (from once a month or more

to twice a week), and very frequent use (from three times a

week to every day) (23). A similar four-level scale was developed

for past-year prescription opioid use.

Mood disorders included DSM-IV major depressive disorder,

dysthymia, bipolar I disorder, and bipolar II disorder.

Anxiety disorders included DSM-IV panic disorder, social

anxiety disorder, specific phobia, and generalized anxiety

disorder. Test-retest reliabilities for AUDADIS-IV mood, anxiety,

and personality disorders in the noninstitutionalized

population and clinical settings have been found to be fair to

good. The criterion validity of mood and substance use disorders

with psychiatrist reappraisal has also been found to be

good to excellent (kappa values, 0.64-0.83) (24). Family histories

of alcohol use disorder, drug use disorders, depression,

and antisocial personality disorder referred to first-degree

relatives. The test-retest reliability of AUDADIS family history

variables has been shown to be very good to excellent (25).

Pain was assessed using the pain item of the Medical

Outcomes Study 12-Item Short Form Health Survey, Version

2 (SF-12) (26), a valid measure that is commonly used in

population surveys (27). The pain item uses a 5-point scale

(not at all, a little bit, moderately, quite a bit, and extremely) to

measure the degree to which pain interferes with daily activities

during the past 4 weeks (28). The pain measure was

collapsed into two levels depending on whether pain was

associated with no or little interference ("no pain"), or with

moderate to extreme interference ("pain") (29).

Statistical Analysis

Wave 1 descriptive demographic and clinical characteristics

were compared between individuals with and without any

48 ajp.psychiatryonline.org Am J Psychiatry 175:1, January 2018

CANNABIS USE AND RISK OF PRESCRIPTION OPIOID USE DISORDER

cannabis use in the year before the wave 1 interview. Group

differenceswere evaluated withchi-square or t tests.Unadjusted

percentages of respondents with wave 2 incident opioid use

disorderswere determined by frequency of wave 1 cannabis use.

Separate logistic regression models were fitted with nonmedical

opioid use and disorder outcomes atwave 2 predicted

by past-year cannabis use at wave 1. To differentiate between

prevalent and incident opioid outcomes at wave 2, we defined

four outcomes: 1) prevalent nonmedical opioid use,

defined as any nonmedical opioid use since the wave 1 interview;

2) incident nonmedical opioid use, defined as any

nonmedical opioid use since wave 1, restricted to respondents

with no lifetime nonmedical opioid use at wave 1; 3)

prevalent prescription opioid use disorder, defined asmeeting

opioid use disorder criteria since wave 1; and 4) incident

prescription opioid use disorder, defined asmeeting opioid use

disorder criteria since wave 1, restricted to respondents with

no lifetimeopioid use disorder atwave 1.Results are presented

as unadjusted odds ratios and adjusted odds ratios controlling

for age, sex, race/ethnicity, family history variables, antisocial

personality disorder, and other substance use disorders and

mood or anxiety disorders at wave 1 (29). Adjusted models of

wave 2 opioid use disorder also controlled forwave 1 past-year

nonmedical opioid use. Regressions were fitted among the

overall population of NESARC wave 1 and 2 respondents and

then repeated, as a sensitivity analysis, among respondents

without wave 1 past-year cannabis use disorders and among

respondents with moderate or more severe pain impairment.

We further examined whether, among respondents with

wave 1 past-year nonmedical opioid use, cannabis use was

associated with an increase or decrease in the level of opioid

use at wave 2. A separate logistic regression was fitted for

respondents with wave 1 opioid use and moderate or more

severe pain. All analyses were performed using SUDAAN to

take into account the complex design features of the NESARC.

RESULTS

Background Characteristics of AdultsWhoUse Cannabis

At wave 1, individuals with any past-year cannabis use were

youngeronaverage than thosewithoutcannabisuse,more likely

to be male, andmore likely to have past-year opioid use disorder,

cannabis use disorder, other substance use disorders, or any

past-yearmood or anxiety disorder.Theywere also significantly

morelikely tohave a familyhistory of alcoholuse disorders,drug

use disorders, depression, and antisocial personality disorder.

The two groups did not differ significantly with respect to the

proportion who reportedmoderate ormore severe pain during

the month before the wave 1 interview (Table 1).

Prospective Associations Between Cannabis Use and

Nonmedical Prescription Opioid Use

Withintheoverall survey population, cannabisuse atwave 1was

associated with a significant increase in the odds of prevalent

nonmedical prescription opioid use during the follow-up period

(Table 2). After adjustment for the background demographic

and clinical characteristics, a strong association persisted between

wave 1 cannabis use and wave 2 prevalent nonmedical

opioid use. These associationswere also observed among adults

without past-year cannabis use disorder and among adultswith

moderate or more severe pain at wave 1. Among individuals

without nonmedical opioid use during the 12 months before the

wave 1 interview, there was a significant association between

cannabis use at wave 1 and incident nonmedical opioid use

during the follow-up period. This association was also observed

among adults without cannabis use disorder at wave 1 and

among adults with moderate or more severe pain at wave 1.

In analyses restricted to individuals with past-year nonmedical

opioid use, in unadjusted and adjusted regressions,

wave 1 cannabis use was significantly associated with an increase

in the level ofopioiduseduring the year before thewave

2 interview. Cannabis use was also associatedwith lower odds

of decreasing the level of opioid use. When the sample was

further restricted to adultswithwave 1 nonmedical opioid use

and moderate or more severe pain, wave 1 cannabis use was

associated with lower unadjusted odds of decreasing opioid

use, although the other regressions did not yield significant

associations. Among individuals with nonmedical opioid use

at wave 1 who either used or did not use cannabis, however,

decreases inopioiduseatwave2weremarkedlymore common

than increases in opioid use (Table 3).

Prospective Associations Between Cannabis Use and

Prescription Opioid Use Disorder

In unadjusted analyses, the percentage of adults who developed

a new-onset opioid use disorder during the follow-up

period was lowest for individuals who did not use cannabis in

the year before the wave 1 interview (0.51%), followed by

occasional cannabis users (2.86%), frequent cannabis users

(4.30%), and very frequent cannabis users (4.43%) (Figure 1).

In the overall survey population, cannabis use at wave

1 was associated with a significant increase in the odds of

prevalent and incident prescription opioid use disorder

during the follow-up period (Table 4). After adjustment for

the background demographic and clinical covariates, including

wave 1 nonmedical opioid use, significant associations

persisted between wave 1 cannabis use and prevalent as

well as incident nonmedical opioid use disorder at wave 2.

A similar association was observed among adults without

past-year cannabis use disorders and prevalent opioid use

disorder, although the association with incident opioid use

disorder fell below the level of statistical significance. Among

adults with moderate or more severe pain at wave 1, cannabis

use was associated with prevalent and incident opioid use

disorders in unadjusted analyses and with prevalent opioid

use disorder in adjusted analyses (Table 4).

DISCUSSION

In a nationally representative sample of adults evaluated at

waves 3 years apart, cannabis use was strongly associated

with subsequent onset of nonmedical prescription opioid use

Am J Psychiatry 175:1, January 2018 ajp.psychiatryonline.org 49

OLFSON ET AL.

and opioid use disorder. These results remained robust after

controlling for the potentially confounding effects of several

demographic and clinical covariates that were strongly associated

with cannabis use. The association of cannabis use

with the development of nonmedical opioid use was evident

among adults without cannabis use disorders and among

adults with moderate or more severe pain.Amongadults with

nonmedical prescription opioid use, cannabis use was associatedwith

an increase in the level of nonmedical prescription

opioid use at follow-up.

An independent prospective association between cannabis

use and onset of prescription opioid use disorder extends

TABLE 2. Prospective Associations of Wave 1 Cannabis Use and Wave 2 Prevalent and Incident Nonmedical Prescription Opioid Use in

the NESARCa

Wave 1 Past-Year Cannabis Use Predicting:

N in

Analysis Odds Ratio 95% CI

Adjusted

Odds Ratiob 95% CI

Overall population

Wave 2 prevalent nonmedical opioid use 34,534 8.74 6.98-10.93 3.54 2.74-4.57

Wave 2 incident nonmedical opioid use 32,888 5.78 4.23-7.90 2.62 1.86-3.69

Population without wave 1 cannabis use disorders

Wave 2 prevalent nonmedical opioid use 34,091 7.43 5.59-9.87 3.35 2.48-4.52

Wave 2 incident nonmedical opioid use 32,616 5.67 3.97-8.09 2.78 1.91-4.04

Population with painc

Wave 2 prevalent nonmedical opioid use 6,920 10.30 6.89-15.39 3.97 2.44-6.46

Wave 2 incident nonmedical opioid use 6,518 6.74 4.09-11.10 2.99 1.63-5.47

a NESARC=National Epidemiologic Survey on Alcohol and Related Conditions; wave 1 was conducted in 2001 and 2002, and wave 2 in 2004 and 2005.

b Adjusted for age, sex, race/ethnicity, other substance use disorders, any mood or anxiety disorder, and family history of drug use disorder, alcohol use disorder,

depression, and antisocial personality disorder at wave 1. The "overall population" and "population without wave 1 cannabis use disorders" analyses were also

adjusted for pain at wave 1.

c Pain is defined as presence of pain causing moderate to extreme interference with daily activities in the past 4 weeks.

TABLE 1. Background Characteristics of NESARC Respondents, by Any Past-Year Cannabis Use at Wave 1a

Characteristic Cannabis Use (N=1,267) No Cannabis Use (N=33,352) p

Mean SD Mean SD

Age (years) 29.91 10.66 45.72 17.27 ,0.001

N % N %

Sex

Male 766 66.49 13,780 47.14 ,0.001

Female 501 33.51 19,572 52.86 ,0.001

Race/ethnicity 0.96

White, non-Hispanic 789 70.82 19,360 70.91

Other 478 29.18 13,992 29.09

Family history

Alcohol use disorders 598 46.51 11,636 33.96 ,0.001

Drug use disorders 427 33.08 5,537 15.97 ,0.001

Depression 614 48.39 10,503 31.98 ,0.001

Antisocial personality disorder 248 21.42 902 2.89 ,0.001

Painb 254 20.06 6,680 18.60 0.29

Nonmedical prescription opioid use,

past 12 months

,0.001

None 1,064 81.92 33,020 98.94

Occasional use 108 10.11 150 0.54

Frequent use 56 4.37 99 0.32

Very frequent use 39 3.61 83 0.21

Mental disorders, past 12 months

Opioid use disorder 45 4.05 58 0.18 ,0.001

Cannabis use disorder 443 36.21 0 0.00 ,0.001

Other substance use disorder 591 48.89 2,160 6.78 ,0.001

Mood or anxiety disorder 440 33.00 5,478 15.53 ,0.001

a NESARC=National Epidemiologic Survey on Alcohol and Related Conditions; wave 1 was conducted in 2001 and 2002. Percentages are based on weighted

sampling.

b Pain is defined as presence of pain causing moderate to extreme interference with daily activities in the past 4 weeks.

50 ajp.psychiatryonline.org Am J Psychiatry 175:1, January 2018

CANNABIS USE AND RISK OF PRESCRIPTION OPIOID USE DISORDER

results from previous epidemiological research concerning

a link between cannabis use and other forms of problematic

drug use (15-17). Previous work in this area has either been

retrospective in design (15) or focused on general associations

between cannabis use and substance use disorders (17) or

problems (16) rather than specifically nonmedical opioid use

or opioid use disorder. Because in the present study the association

was observed among adults with less than disorderlevel

of cannabis use and followed a dose-response pattern, it

suggests that some increased risk extends to a relatively large

population of adult cannabis users. If cannabis use tends to

increase opioid use, it is possible that the recent increase in

cannabis use (30) may have worsened the opioid crisis.

Several factors may contribute to a tendency for individuals

with cannabis use to develop opioid use disorder or

increase the frequency of opioid use among opioid users.

Heroin and D9-tetrahydrocannabinol (D9-THC) have similar

effects on dopamine transmission through the m1 opioid

receptor (31). As compared with controls, adolescent rats

exposed to D9-THC have been shown to develop enhanced

heroin self-administration as adults (32). Also in relation to

controls, rats exposed to D9-THC have been found to have a

greater behavioral response tomorphine challenge (33).These

results are consistent with cross-sensitization between cannabis

and opioids. In clinical research, cannabis use can lead

to behavioral disinhibition, which can increase the risk of

using other substances, including opioids (34). Access to

cannabis may also provide increased availability and social

exposure to other drugs of abuse through peer affiliations

(35), although such environmental influences may be less

powerful in recent yearswithincreasedprevalence ofcannabis

use and changing public attitudes.

Ecological studies reporting fewer opioid-related deaths

(8, 9) and decreased opioid prescribing following passage of

medical marijuana laws (10) have been interpreted in the

TABLE 3. Prospective Associations Between Wave 1 Cannabis Use and Increase or Decrease in Nonmedical Prescription Opioid Use at

Wave 2 Among Adults With Wave 1 Nonmedical Prescription Opioid Use in the NESARCa

Wave 1 Past-Year

Cannabis Use Predicting:

Respondents With Change in Opioid Use

Between Wave 1 and Wave 2

Cannabis Use No Cannabis Use

N % N % Odds Ratio 95% CI

Adjusted

Odds Ratiob 95% CI

Adults with wave 1

nonmedical opioid use

203 332

Increase in opioid use

at wave 2

9 5.15 4 0.97 5.57 1.47-21.11 3.13 1.19-8.23

Decrease in opioid use

at wave 2

169 81.27 307 93.70 0.29 0.14-0.61 0.42 0.19-0.91

Adults with wave 1

nonmedical opioid

use and painc

60 105

Increase in opioid

use at wave 2

2 7.78 3 1.97 4.20 0.64-27.50 2.60 0.42-16.05

Decrease in opioid

use at wave 2

53 79.97 96 93.04 0.30 0.10-0.86 0.60 0.18-2.03

a NESARC=National Epidemiologic Survey on Alcohol and Related Conditions; wave 1 was conducted in 2001 and 2002, and wave 2 in 2004 and 2005. Percentages

are based on weighted sampling.

b Adjusted for age, sex, race/ethnicity, other substance use disorders, any mood or anxiety disorder, and family history of drug use disorder, alcohol use disorder,

depression, and antisocial personality disorder at wave 1.

c Pain is defined as presence of pain causing moderate to extreme interference with daily activities in the past 4 weeks.

FIGURE 1. Level of Wave 1 Cannabis Use and Incident Wave

2 Prescription Opioid Use Disorder in the NESARCa

4.5

4.0

5.0

3.5

3.0

2.5

2.0

1.5

1.0

0.5

0

Level of Wave 1 Cannabis Use

Wave 2 Opioid Use Disorder (%)

No use Occasional

use

Frequent

use

Very frequent

use

a NESARC=National Epidemiological Survey on Alcohol and Related Conditions;

wave 1 was conducted in 2001 and 2002, and wave 2 in 2004 and

2005.

Am J Psychiatry 175:1, January 2018 ajp.psychiatryonline.org 51

OLFSON ET AL.

media (6) and scientific literature (7) as supporting cannabis

as a means of reducing opioid use disorder. Yet

drawing inferences about the behavior of individuals from

aggregated data can be misleading. It is possible, for example,

that passage of medical marijuana laws increased

local clinical awareness of opioid misuse, leading to earlier

detection of high-risk patients or more cautious opioid

prescribing practices. At the individual level, cannabis use

appears to substantially increase the risk of nonmedical

opioid use. Moreover, the general association between

cannabis use and subsequent use of illicit drugs is not

explained by the legal status of cannabis. An association of

early cannabis use with increased subsequent risk of other

drug abuse has been reported in prospective co-twin

studies in Australia (15), which has restrictive cannabis

laws, and in the Netherlands, where cannabis is readily

available (36).

In accord with previous studies, several demographic and

clinical covariates were associated with cannabis use (17).

These findings converge to highlight the wide range of factors

that may influence initiation of cannabis. However,

because cannabis use was not associated with significant pain

at baseline, relief from pain does not appear to be a strong

determinant of cannabis use in the general U.S. adult population,

although we have no means of evaluating the analgesic

effects of cannabis with NESARC data.

This study has several limitations. First, the NESARC

sampled individuals age 18 and older. The relationship between

cannabis and opioid use may differ in younger individuals

(16). Second, information on cannabis and opioid use

was based on self-report and was not confirmed with urine

toxicology, which may have led to underestimates. Third,

the analysis was limited to two time points 3 years apart,

which may have been too short an interval to observe

delayed consequences of cannabis use onlater risk of opioid

use. Fourth, the data were collected over a decade ago, and

the social context of cannabis usemay have changed during

this period (30). Nevertheless, the NESARC remains the

most recent nationally representative prospective cohort

of U.S. adults with detailed information on substance use.

Fifth, we were unable to distinguish recreational from

medical marijuana use. However, typical medical marijuana

participants have been reported to be young males

with a history of recreational cannabis use (37), and adults

often combine medical and nonmedical cannabis use (38).

Sixth, some of the associations are based on a small number of

individuals and should therefore be interpreted with appropriate

caution. Seventh, the NESARC did not assess inmate

populations, which may have a high prevalence of substance

use disorders (39). Finally, the assessment of nonmedical use

of prescription opioids, although extensive, was not exhaustive

and included two nonopioid medications (celecoxib and

rofecoxib).

A long-standing controversy in drug research and policy

concerns the extent to which use of cannabis predisposes to

subsequent use of opioids and other drugs of abuse.We report

that cannabis use, even among adults with moderate to severe

pain, was associated with a substantially increased risk of

nonmedical prescription opioid use at 3-year follow-up.

Although the great majority of adults who used cannabis

did not go on to initiate or increase their nonmedical opioid

use, a strong prospective association between cannabis and

opioid use disorder should nevertheless sound a note of

caution in ongoing policy discussions concerning cannabis

andin clinical debate over authorization of medical marijuana

to reduce nonmedical use of prescription opioids and




QUESTION 1

1.    What measure of disease frequency, association, and/or impact was calculated to answer the main research question(s)? Please answer in complete sentences.


5 points  

QUESTION 2

1.    How well did the study participants represent the larger population from which they were selected? Explain any concerns about generalizability with the study results.


5 points  

QUESTION 3

1.    How do the results of this study fit with other studies done on this topic? Base your answer on the information discussed in the article (you may include information from outside references, but it is not required). Please answer in complete sentences.


5 points  

QUESTION 4

1.    What potential effect modifiers were assessed in the study, and how were they assessed? Please answer in complete sentences.



5 points  

QUESTION 5

1.    What epidemiological study design was used in this study? Please answer in complete sentences.


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QUESTION 6

1.    What potential confounders were measured and adjusted for in the study? Please answer in complete sentences.


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QUESTION 7

1.    What ethical concerns are raised by this study? Discuss any procedures the authors used to minimize or eliminate these concerns. Please answer in complete sentences.


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5 points  

QUESTION 8

1.    Given what you have learned in this course about confounding, was the adjustment for confounding adequate, or is residual confounding a concern? Explain using complete sentences.


- 5 points  

QUESTION 9

1.    What types of information bias might be affecting this study? Please describe the biases and how they might be affecting the results of the study. Please answer in complete sentences.


5 points  

QUESTION 10

1.    What was/were the research question(s) that the study was answering? Please answer in complete sentences.



5 points  

QUESTION 11

1.    What was/were the exposure(s) of interest in the study? If there is more than one, list all of them.


5 points  

QUESTION 12

1.    What types of selection bias might be affecting this study? Please describe the biases and how they might be affecting the results of the study. Please answer in complete sentences.


5 points  

QUESTION 13

1.    What are the strengths of the study, and how do these strengths impact how the study results are interpreted? Please answer in complete sentences.


- 5 points  

QUESTION 14

1.    What are the limitations of the study, and how do these limitations impact how the study results are interpreted? Please answer in complete sentences.


5 points  

QUESTION 15

1.    Please describe the major results of the study. Include the major numerical/statistical results as well as interpretations of them in your own words.

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