State Medical Cannabis Laws, Chronic Pain, and Opioids: A Mixed-Methods Approach

摘要 33个州和华盛顿特区颁布了医用大麻法，允许慢性非癌症患者 疼痛使用大麻，当医生建议，以管理他们的病情。决策者 越来越多地考虑将州医用大麻法作为美国阿片类药物危机的潜在解决方案， 一些患者可能会用大麻代替处方阿片类药物来治疗慢性非阿片类药物， 癌症疼痛，并因此降低阿片类药物使用障碍和过量的比率。然而，严格的证据表明， 缺乏：没有研究检查了州医用大麻法对阿片类药物相关结果的影响 在一组慢性非癌症疼痛患者中。此外，没有现有的研究已经研究了如何 国家医用大麻法律影响慢性非癌症疼痛患者接受指南一致的非阿片类药物 疼痛治疗或这些法律如何影响大麻使用障碍和中毒的慢性非- 癌症疼痛状况，如腰痛或关节炎。重要的是，以前的研究没有考虑过 各州医用大麻法律之间以及各州内部的规定和实施存在相当大的差异 随着时间的推移，随着各州修改法律和改变实施规则， 患者我们的研究采用了混合方法的方法，将准实验差异中的差异 分析;与国家政策和医疗保健领导人的定性访谈;以及 治疗的医生和经历慢性非癌症疼痛的患者来填补这些研究空白。使用 50-州数据源，包括Medicare和Optum UnitedHealthcare行政索赔数据，我们将 检查州医用大麻法律对接受处方阿片类药物和指南一致性的影响 非阿片样物质药理学（例如，抗惊厥药）和非药物（例如，物理治疗）疼痛 治疗（目标1）。我们还将使用这些数据来研究州医用大麻法律对 接受阿片类药物使用障碍、阿片类药物过量、大麻使用障碍和大麻中毒治疗 慢性非癌性疼痛患者（目标2）。我们将对国家政策进行定性采访 和医疗保健系统的领导人，以确定国家医用大麻法的实施情况， 慢性非癌性疼痛（目标3）。最后，我们将对初级保健医生进行有代表性的调查， 疼痛专家，以及在有医用大麻法律的州患有慢性非癌症疼痛的患者。调查将 捕获与医用大麻法律相关的关键态度和报告的行为，包括 医生报告建议和患者报告使用大麻代替阿片类药物治疗慢性 非癌性疼痛（目标4）。在所有目标中，我们将考虑法律规定和执行的差异 影响慢性疼痛治疗。结果将产生国家决策者所需的信息， 实施新的医用大麻法律以及考虑改变现有医用大麻的法律 法律的规定和实施。

ABSTRACT Thirty-three states and D.C. have enacted medical cannabis laws allowing patients with chronic non-cancer pain to use cannabis, when recommended by a physician, to manage their condition. Policymakers are increasingly considering state medical cannabis laws as a potential solution to the U.S. opioid crisis, with the idea that some patients may substitute cannabis in place of prescription opioids for treatment of chronic non- cancer pain and reduce rates of opioid use disorder and overdose as a result. However, rigorous evidence is lacking: no studies have examined the effects of state medical cannabis laws on opioid-related outcomes among a cohort of patients with chronic non-cancer pain. Further, no existing research has examined how state medical cannabis laws affect chronic non-cancer pain patients’ receipt of guideline-concordant non-opioid pain treatments or how such laws affect cannabis use disorder and poisoning among those with chronic non- cancer pain conditions like low back pain or arthritis. Critically, no prior studies have considered how the considerable variation in provisions and implementation across state medical cannabis laws, and within states over time as states amend their laws and change implementation rules, affect outcomes for chronic pain patients. Our study uses a mixed-methods approach incorporating quasi-experimental difference-in-differences analyses; qualitative interviews with state policy and healthcare leaders; and representative surveys of physicians who treat and patients who experience chronic non-cancer pain to fill these research gaps. Using 50-state data sources including Medicare and Optum UnitedHealthcare administrative claims data, we will examine the effects of state medical cannabis laws on receipt of prescription opioid and guideline-concordant non-opioid pharmacologic (e.g., anticonvulsants) and non-pharmacologic (e.g., physical therapy) pain treatments (Aim 1). We will also use these data to examine the effects of state medical cannabis laws on receipt of treatment for opioid use disorder, opioid overdose, cannabis use disorder, and cannabis poisoning among patients with chronic non-cancer pain (Aim 2). We will conduct qualitative interviews with state policy and healthcare system leaders to characterize implementation of state medical cannabis laws for treatment of chronic non-cancer pain (Aim 3). Finally, we will conduct representative surveys with primary care physicians, pain specialists, and patients with chronic non-cancer pain in states with medical cannabis laws. Surveys will capture key attitudes and reported behaviors related to medical cannabis laws, including the degree to which physicians report recommending and patients report using cannabis in place of opioids for treatment of chronic non-cancer pain (Aim 4). In all Aims, we will consider how differences in law provisions and implementation influence chronic pain treatment. Results will yield information needed by state decision-makers considering implementing new medical cannabis laws as well as those considering changes to existing medical cannabis laws’ provisions and implementation.