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Opioids versus Cannabinoids

Most of us in the AOD prevention business are not medically trained, however we are often asked to weigh in on medical matters. The recent focus on prescription drug abuse is one example of this. Another is medical marijuana.

Two recent events bring these two topics together, highlighting the conflicts that are brewing within the field. First, a story that pharmaceutical companies appear to be racing to get a pure Hydrocodone (the opiate in Vicodin) approved and to market (Huffingtonpost, 12/26/11). The second is a scientific research paper published that demonstrates that cannabinoids may allow for a reduction in opioid doses needed to manage pain (Abrams, Couey, Shade, Kelly, & Benowitz, 2011).

The story that a new, possibly crushable time-release opioid may hit the market sends shivers down the spine of anyone who already is working to reduce OxyContin abuse. Apparently, the Vicodin mixture of Hydrocodone and Acetominophen can cause negative side effects such as kidney damage because of the high dose of Acetominophen within it; thus the need for a pure form. But it is hard to imagine that the drug will remain solely in the medical setting; addiction and overdoses are predictable outcomes of a pure version of such a widely abused opioid (CDC Vital Signs). But we must also not lose sight of the pain relief that these medicines are rightly providing.

So what does this have to do with medical marijuana? The Abrams and colleagues (2012) study may point to ways of using active agents within marijuana to lessen the need for opiates in pain management. But those of us who are worried that the current direction for implementing medical marijuana may be ignoring public health consequences of greater access cringe at the direction such line of thinking leads.

So this means, prevention efforts need to remain flexible to the direction medical management of pain advances may lead. Conflicting pressures may at some point in the future make it necessary to consider the harm reduction value of new approaches to pain management. However, we must continue to remind the health and regulatory communities about the risks diverted medicines pose to public safety.

References:

Abrams, D. I., Couey, P., Shade, S. B., Kelly, M. E., & Benowitz, N. L. (2011). Cannabinoid-Opioid Interaction in Chronic Pain. Clin Pharmacol Ther, 90(6), 844-851.

CDC Vital Signs - Prescription Painkiller Overdoses in the US. Retrieved January 18, 2012, from http://www.cdc.gov/Vitalsigns/PainkillerOverdoses/index.html

Zohydro, Pure Hydrocodone Prescription, Concerns Painkiller Abuse Experts. (12/26/11). Retrieved January 5, 2012, from http://www.huffingtonpost.ca/2011/12/26/zohydro-pure-hydrocodone-vicodin_n_1170104.html

 

Medical Marijuana Laws Reduce Drunk Driving?: Not so fast!

Perhaps you've heard of a recently released study on the effect of medical marijuana on traffic fatalities.  The study by Mark Anderson and Daniel Rees is presented as a discussion paper posted on the IZA website.  It is not peer reviewed.  What is astounding is that the authors find that Medical Marijuana Laws (MML) reduce alcohol related fatalities, and in fact reduces overall deaths by 9%.  This startling finding, they explain, is the result of marijuana replacing alcohol use among young, high risk drivers.  They argue that either marijuana is safer, or is used in safer contexts than alcohol, and therefore this replacement is protective.

Read more: Medical Marijuana Laws Reduce Drunk Driving?: Not so fast!

Driving risk at very low BAC levels

There is a bit of media buzz about a new study on drinking and driving authored by researchers at UCSD (Phillips & Brewer, 2011). In short, the researchers analyzed the Fatality Analysis Reporting System (FARS) data to find a relationship between BAC and vehicle crash injury and death. What was unique about their study was that instead of analyzing BAC categories (typically 0.0, .01-.09, .10+), the researchers left the BACs in units of .01. That meant that they could look for crash-risk increases even at very low levels… even .01 BAC.

Read more: Driving risk at very low BAC levels

Minors in possession vs. Marijuana possession

 

For those under 21, California now has more severe punishments for alcohol than marijuana. On January 1, 2011 SB 1449 went into effect making possession of one ounce or less of marijuana an infraction. There is no age restriction on this law and thus those under 21 would face the same $100 fine as adults for a violation, though it appears a minor's license may still be revoked. Further, because it is an infraction, there is no court record, stepped up punishments for repeat offenders or education/treatment referrals. Possession of marijuana in a vehicle (notwithstanding impaired driving violations) will garner the same $100 fine. Only possession of more than an ounce, possession of concentrated marijuana, or possession on K-12 school grounds is considered a misdemeanor.

Read more: Minors in possession vs. Marijuana possession

Marijuana Impaired Driving

For alcohol we have a driving per se limit: 0.08 g/dl. This means that if a driver has a BAC at or above 0.08 g/dl, he/she is presumed impaired and can be charged with DUI. But for marijuana, we have no such limit. So while high school seniors are more likely to report driving after smoking marijuana than driving after heavy drinking (O'Malley & Johnston, 2007), enforcement is hampered by vague guidelines for impairment.

Indeed there are perceptions among some in our target population that marijuana does not impair driving at all. Some claim that the tendency of marijuana users to drive slowly makes them better drivers. But recent research contradicts this belief, and there is general consensus that driving under the influence of cannabis is a serious public health concern.

A few years ago, a panel of experts came together to study the issue of THC limits for driving. Their report (see Grotenhermen et al., 2007) offers a nice overview of the research that has documented the crash risks associated with various THC blood levels. It’s clear that marijuana researchers have the work cut out for them; while we have roadside alcohol breath tests since the late 1930’s, there is still no good roadside equivalent for THC. However, the panel was able to make some very specific recommendations based upon laboratory research as well as sound epidemiological data. They recommend a per se limit of between 7 and 10 ng/ml THC blood level.

So this means we should be informing our students about the risks of marijuana impaired driving. To avoid driving over the safe limit, a marijuana user must allow for the passage of time. Using marijuana is different than drinking alcohol. Almost any use of cannabis will cause a spike well above 7 ng/ml. But that spike will dissipate rather quickly. By waiting 3 hours from the last use, the driver will likely be well below the recommended limit and also likely not still be experiencing any substantial impairments.

Finally, the limits recommended for THC change dramatically with even low levels of concurrent alcohol use. Mixing alcohol with marijuana substantially increases crash risk. Students should be explicitly warned about this, and encouraged to use designated drivers who will remain completely sober to assure everyone get’s home safely.

References

Grotenhermen, F., Leson, G., Berghaus, G., Drummer, O. H., Krüger, H., Longo, M., Moskowitz, H., et al. (2007). Developing limits for driving under cannabis. Addiction, 102(12), 1910-1917.

O'Malley, P. M., & Johnston, L. D. (2007). Drugs and driving by American high school seniors, 2001-2006. Journal of Studies on Alcohol and Drugs, 68(6), 834-842.

 

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