Elsevier

Drug and Alcohol Dependence

Volume 159, 1 February 2016, Pages 101-108
Drug and Alcohol Dependence

Full length article
Nonmedical prescription pain reliever and alcohol consumption among cannabis users

https://doi.org/10.1016/j.drugalcdep.2015.11.039Get rights and content

Highlights

  • Over time, the prevalence of cannabis increased but pain reliever misuse declined.

  • Over time, poly-drug use involving dual use of cannabis and pain reliever misuse declined

  • Higher levels of cannabis use was positively associated with pain reliever misuse.

Abstract

Background

This study examined poly-drug use involving the use of cannabis with nonmedical prescription pain reliever use (NMPR) and alcohol use.

Methods

Computer-assisted survey data from the National Survey on Drug Use and Health were examined. The NSDUH is an annual, cross-sectional survey of non-institutionalized citizens in the United States (ages 12+). Replicate analyses were conducted using the 2013 and 2003 survey waves.

Results

Higher levels of cannabis use were consistently associated with more frequent consumption of prescription pain relievers, with findings replicating in both 2013 and 2003. While the prevalence of dual users declined from 2003 (2.5%) to 2013 (2.3%), the average number of days used among dual users increased by an average of 20 days over that period. These changes largely occurred among those aged 35 or older, males, whites, and non-illicit drug users. Past-year marijuana use increased by 16% (10.8–12.6%, p-value < .001) whereas NMPR decreased by 15% (4.9–4.2%, p-value < .001). The largest changes occurred after 2011. Persons using the most cannabis generally had higher levels of alcohol use relative to those using the least amount of cannabis. There was a significant increase in the prevalence of dual use between 2003 (10.2%) and 2013 (11.6%), while the prevalence of past-year alcohol use remained relatively stable.

Conclusions

Clinical efforts and public health interventions should consider the possible co-ingestion of cannabis with NMPR and alcohol, as concomitant use may portend negative health effects in the short and long-term.

Introduction

Cannabis is one of the most commonly used drugs in the United States. Despite recent state legislation that permits use for medical and even recreational use in some states, cannabis remains classified as an illegal substance at the federal level (SAMHSA, 2014). Motivations for use include the self-medication of pain, reduced anxiety and tension, intoxication, and even increased sociability (Hayaki et al., 2010). It is not surprising that users report different motivations for consumption, as over 400 different pharmaceutical agents have been isolated in the cannabis plant (Kogan and Mechoulam, 2007). The two primary pharmacological agents in cannabis are cannabidiol (CBD) and Δ9-tetrahydrocannabinol (THC). CBD is responsible for its anxiolytic and anti-inflammatory properties. Because of its efficacy as a pain reliever, some users may prefer cannabis over opioids as a frontline treatment for pain (Lucas, 2012). Laboratory studies provide evidence that users may be drawn to cannabis as a result of its strong intoxicating effect, primarily due to its THC content (Watson and Benson, 2001). This underscores the possibility that cannabis may be used as a substitute for alcohol as well, likely because it produces feelings of tension reduction that are similar to alcohol.

There are several possible relationships that can be used to describe patterns of dual use involving cannabis and other licit and illicit drugs. The term “substitution” effect has been used to describe the behavioral phenomena in which an individual freely chooses to consume one substance as a replacement for another substance. In contrast to substitution, use may also occur in a complementary fashion, such as using a second drug as a way to augment the effects of a primary drug. For example, a case study of pain clinic patients reported that promethazine can augment the feelings of euphoria among those using prescription pain reliever products (Lynch et al., 2015). Substances that are ingested by the same person can have markedly different effects depending upon their pharmacokinetics, absorption and distribution throughout the body (FDA, 2015). Understanding the pattern of dual use has important clinical and public health implications in terms of short-term (e.g., overdose) and long-term (e.g., hepatic functioning) health effects.

A first step to determining the nature of the relationship between one or more substances is to first examine their consumption practices more broadly. Typically, self-report data are used to indicate whether use has occurred in a given period. Prior studies have shown using binary indicators that the likelihood of alcohol use and prescription pain reliever misuse is higher among cannabis users compared to non-cannabis users (Compton et al., 2004). Others have examined use of one substance during periods of abstinence involving another substance. For example, Allsop et al. (2015) found increases in tobacco and alcohol use during periods of abstinence from cannabis (Allsop et al., 2015).

A limitation to the indicator approach is that persons using more frequently are coded the same as those using just once or twice. Examining levels of use overcomes this limitation by establishing whether a user favors one substance relative to another based on quantity measures. A study by Kral et al. (2015) examined the possibility that cannabis may be used as a substitute for opioids by comparing the frequency of use as reported for both substances. The authors found a negative relationship between cannabis use and opioid use, and drew upon those findings to support a substitution hypotheses. One limitation of this approach is that the relationship is established only by the number of days each substance was used. The quantitative measures of consumption do not provide direct evidence for a causal relationship because it is not possible to establish the actual number of days the substances were actually used together. However, this correlational exposure approach does have utility, as the number of days a product was used can help identify preferences for one product relative to another. The number of days a substance was used in a month is also a fairly simple measure to report, so it is widely available on most surveys of drug use. Data on concomitant use are lacking on many surveys, likely because it is a complicated behavioral pattern to measure. The current study draws on the correlational approach, but conducts a series of sensitivity analyses by examining the stability of the findings across different observational periods, as well as examining whether the relationships are similar across related substances.

The goal of the current study was to examine the dual use of cannabis with prescription pain relievers and alcohol. As much of the prior studies used small, community-based samples that were largely cross-sectional, the current study overcomes those previous limitations in using data from the 2003 to 2013 National Survey on Drug Use and Health. The NSUDH is only available for public use through the year 2013, prior to the first statewide retail legalization of cannabis in 2014. To provide an understanding of the stability of the relationships, the analyses were replicated using 2013 and 2003 NSDUH data. There was a major NSDUH redesign in 2003, which precluded comparisons to previous years. Therefore, the data available for analyses were only between the years from 2003 to 2013.

It is important to note that this study is not meant to estimate the impact of policy changes that may have occurred during this 10-year period on substance use behaviors. Yet, it is important to recognize the larger cultural environment during this time. Before 2003, three states legalized cannabis for medicinal purposes only. Between 2003 and 2013, seventeen additional states legalized medical cannabis. In 2014, cannabis was legalized for retail purposes in Colorado and Washington, and later in the District of Colombia, Oregon and Alaska. While access to cannabis certainly increased during this period, numerous policies were also implemented to restrict access to prescription pain relievers, such as prescription drug monitoring programs and medication take-back programs (Gugelmann and Perrone, 2011, Manchikanti, 2006). Inspection of the data over time can provide a sensitivity analyses that controls for the influence of environmental factors on usage. In light of this, the goal of the current work is to evaluate the dual use of cannabis with NMPR and alcohol using nationally representative data collected over multiple years.

Section snippets

Methods

The National Survey on Drug Use and Health (NSDUH) is an annual computer-aided, interviewer-assisted survey of non-institutionalized U.S. civilians aged 12 years or older. Additional sample details are available elsewhere (SAMHSA, 2014). The yearly data from 2003 to 2013 were used to test for trends in substance use over time. The 2003 and 2013 data sets were used for the rest of the analyses presented in this study. The unweighted sample sizes were approximately 55,000 per year. Past-year

Results

Fig. 1 shows the linear trend between 2003 and 2013, and specifically that the prevalence of cannabis users aged 12 or older in the United States increased from 10.8% to 12.6%. The fitted predicted probability trend line showing the positive change is also presented (Chi-Square 1316210, 1df, P < .001). In contrast, the prevalence of NMPR decreased from 4.9% to 4.2% over that same 10-year period. The linear trend showing a decline (Chi-square = 127863, 1df, P < .001) is also presented. Note that there

Discussion

This study investigated the nature of the relationship between the dual use of cannabis and NMPR as well as cannabis and alcohol use. We observed that more frequent use of cannabis was associated with more frequent use of NMPR, with findings replicating in 2013 and 2003. Kral et al. (2015) reported data somewhat counter to our findings, showing an inverse relationship between the number of times cannabis was used in relation to the proportion of opioid users in each category of marijuana use.

Conflicts of interest

The authors have none to declare.

Contributors

SPN conceptualized the study and drafted the paper. NCP conducted the analyses and wrote the methods and results section. SN, NCP, and GAZ conceptualized the analysis of the paper. All authors reviewed and approved changes to the final manuscript.

Funding

Support for the writing of this paper was conducted with funding from the National Institute on Drug Abuse (NIDA, R01DA030427) and the Substance Abuse and Mental Health Services Administration.

References (18)

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