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律，允许慢性非癌症患者 当医生建议使用大麻来控制病情时，他们会感到疼痛。决策者们正在 越来越多地考虑将州医用大麻法律作为美国阿片类药物危机的潜在解决方案， 认为一些患者可能会用大麻代替处方阿片类药物治疗慢性非传染性疾病 癌症疼痛和降低阿片类药物使用障碍和过量服药的结果。然而，严格的证据是 不足：没有研究检查国家医用大麻法律对阿片类药物相关结果的影响 在一组患有慢性非癌症疼痛的患者中。此外，现有的研究还没有研究如何 国家医用大麻法律影响慢性非癌症疼痛患者接受符合指南的非阿片类药物 疼痛治疗或这些法律如何影响大麻使用障碍和中毒那些慢性非 癌症疼痛状况，如腰痛或关节炎。关键的是，之前没有任何研究考虑过 各州医用大麻法律的条款和执行情况有很大差异，各州之间也有很大差异 随着时间的推移，各州修改法律和改变实施规则，会影响慢性疼痛的结果 病人。我们的研究采用了混合方法，结合了准实验差异法。 分析；对国家政策和医疗保健领导人的定性采访；以及对 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。vbl.使用 50个州的数据来源，包括Medicare和Optus UnitedHealthcare管理索赔数据，我们将 审查国家医用大麻法律对处方阿片类药物和指南一致性的影响 非阿片类药物(如抗惊厥药)和非药物(如理疗)疼痛 治疗(目标1)。我们还将使用这些数据来检查州医用大麻法律对 接受治疗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 在慢性非癌性疼痛患者中(目标2)。我们将就国家政策进行定性采访 和医疗系统领导人描述国家医用大麻法律的实施情况，以治疗 慢性非癌性疼痛(目标3)。最后，我们将对初级保健医生进行具有代表性的调查， 疼痛专家，以及有医用大麻法律的州的慢性非癌症疼痛患者。调查将 掌握与医用大麻法律有关的关键态度和报告的行为，包括以下程度 医生报告建议和患者报告使用大麻替代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实施方面的差异 影响慢性疼痛的治疗。结果将产生州决策者考虑所需的信息 执行新的医用大麻法律以及考虑修改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.