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States with Medical Marijuana Have Fewer Painkiller Deaths (smithsonianmag.com)
209 points by robg on Aug 30, 2014 | hide | past | web | favorite | 38 comments

Side note: acetaminophen is a much bigger threat than most opioid analgesics themselves. It's directly involved in something like 10% of all overdoses in the US. There's no practical reason for opioids like hydrocodone to be mixed with it (as opposed to just being prescribed/administered concurrently) except that you get sick if you try to take enough of the opioid to get high. Personally, I feel that hepatotoxicity is a poor abuse deterrent, both in theory and practice.

There are around 115 U.S. acetaminophen deaths per year, versus around 17k opioid analgesic deaths. That said, as far as I can tell there is no reason to take it acetaminophen ever; for pretty much any use case, there is another drug that's more effective and safer.



>There are around 115 U.S. acetaminophen deaths per year, versus around 17k opioid analgesic deaths.

First, I said "overdoses", not "overdose deaths". There is a difference.

The source you cited doesn't make it clear whether the known opioid deaths did or did not involve acetaminophen. Since hydrocodone, oxycodone, codeine, dihydrocodeine, and tramadol are all combined with acetaminophen, I'd guess the intersection of the two sets is significant.

The FDA recognized this problem and cut the APAP dose in combination analgesics to a maximum of 325mg (compared with the recommended 500mg dose of APAP alone) in 2009. They did not restrict the opioid dosages because they weren't responsible for the toxicity.

There are some painkillers that contain both; which column do those go in?

Whichever one kills you. The Tylenol takes several days to kill you, whereas the opiates would be entirely worn off by then, so it should never be ambiguous.

The article clearly states that there were 16,651 overdose deaths "involving" opioids. It does not say anything about cause of death or exclusion of other drugs.

Can you elaborate more on the acetaminophen alternatives? We've been using it in my family, and would love to do better.

try advil

Do you mean ibuprofen? Long term that's going to be rough on your stomach.

I've had a long history of headaches and ibuprofen is something I'm taking a few times a week and have been since I was 11 or 12. I've never had stomach issues.

If you take it with a meal you won't have problems.

That's way better than rough on your liver.

Long term use of paracetamol at the therapeutic dose is not rough on your liver.

What? Paracetamol, when taking correctly, is very safe and effective. The toxic dose is close to the therapeutic dose so care needs to be taken to avoid overdose and acute overdose is particularly dangerous.

>when taken correctly, is very safe and effective.

...is tautological and could be said about almost anything.

The fact that the toxic dose is close to the therapeutic dose means that it is not safe.


"Liver toxicity from acetaminophen poisoning is by far the most common cause of acute liver failure in the United States, researchers reported."

> "Liver toxicity from acetaminophen poisoning is by far the most common cause of acute liver failure in the United States, researchers reported."

But that's because paracetamol is deliberately used as a self-poisoning method. Very few of those acute overdoses are accidental. Although they do happen accidental overdose is usually old people storing meds in the wrong place and children getting access.

Very few people accidentally overdose on paracetamol by doubling up on paracetamol containing meds - and the solution is better packaging and warnings.

There are some things that help reduce overdosing. Restricting the sale of paracetamol to blister packs only, and not bottles, does help.

(Neither you nor Alex3917 have suggested a safer off the shelf alternative)

The majority of the cases studied in the linked article (in the cases where it was known) were accidental.

"Some people deliberately take toxic doses in suicide attempts, but others may accumulate high levels of acetaminophen unintentionally when they take, for example, Tylenol for a headache and a second acetaminophen-containing product for cold symptoms."

Also people overdose when they're hung over.

>(Neither you nor Alex3917 have suggested a safer off the shelf alternative)

And I don't intend to. Ask a doctor. I have no idea why you use it, or if any suggestion of mine would cover that usage. I never find any reason to use anything stronger than aspirin, and Advil was suggested earlier in the thread.

This American Life did a fantastic piece on acetaminophen, how easy it is to overdose on it, and the story behind why it's still thought of as so safe. Interesting listening on this topic!


I haven't read the scientific study on JAMA, but I would venture to speculate that there could be several reasons for such sharp drops in mortality due to opioid overdoses:

- fewer people resort to opioids for recreational purposes, due to higher availability of marijuana

- alcohol + opioids is a deadly combination. People who are high on marijuana tend to drink less, because alcohol doesn't go well with marijuana either. Marijuana, however, can be combined with many drugs and tends to enhance the experience, requiring less of the drug.

- Marijuana makes people more cautious and health-conscious due to it's capacity to induce temporary paranoia and anxiety at larger doses.

A quick google search for 'marijuana combined with heroin' led me to a forum where people are reporting full-blown panic attacks when combining the two, with users generally reporting that the two drugs tend to enhance one another. Such panic attacks are powerful experiences and can be life-changing in a positive way.

Several countries have eased on marijuana prohibition due to the opiod addiction problem getting out of control (Switzerland, Portugal, Spain and probably other countries) and as a consequence saw decreases in overdoses and HIV infections so this study just corraborates what has been observed in other places around the world.

Marijuana and Alcohol are considered economic compliments actually. The more you smoke the more likely you are to drink and vice versa.

It looks like the research on this is mixed.


The Legalization of Recreational Marijuana: How Likely is the Worst-Case Scenario?, with Daniel Rees. Journal of Policy Analysis and Management 33 (2014) 221-232.[1]


Williams, Jenny, Rosalie Pacula, Frank Chaloupka, and Henry Wechsler. 2004. “Alcohol and Marijuana Use among College Students: Economic Complements or Substitutes?” Health Economics 13: 825-843.[2]

It seems that the research based on natural experiments is intrinsically better than the price-related studies, and so far, that indicates that marijuana legalization reduces alcohol consumption.

Anderson's research also indicates that medical marijuna legalization resulted in a significant decrease in traffic fatalities, which is a huge win.[3]




PDFs may differ from published versions.

"generally reporting that the two drugs tend to enhance one another"

Considering they're both CNS depressants this makes sense

"However, the study authors caution that their analysis doesn’t account for health attitudes in different states that might explain the association."

As the article suggests, correlation does not equal causation. Looking at this map: https://en.wikipedia.org/wiki/File:Map-of-US-state-cannabis-...

one can imagine numerous other reasons that might lead to differential rates of painkiller (ab)use between states. Socioeconomic status is fairly clear to me (states with higher status are more likely to have medical marijuana), other correlations are a bit more of a can of worms.

They do account for unemployment, but I agree with you. More evidence needed.

It sure hasn't stopped those for it from pointing to this article.

I'm a big fan of recreational weed (ideally sativa strains), but my experience with indica strains for pain relieve is not good. I find that rather than making me forget about chronic pain that I currently experience (neck cramps, sore muscles, etc) it makes me remember/re-experience pain from years-old injuries. Surgical scars I got when I was in my teens and haven't felt since suddenly have dull unignorable sensations of pain. A toe I broke a year ago starts hurting again. Etc.

Nobody that I have mentioned this too has ever said they experienced the same so I've usually just written it off as some sort of strange psychosomatic thing, but the article's passing mention that "marijuana doesn’t replace the pain relief of opiates. However, it does seem to distract from the pain by making it less bothersome." makes me wonder if something is actually going on here.

Sativa is probably the better strain for pain relief, as it contains primarily THC (which is analgesic), whereas indicas contain roughly equal amounts of THC and CBD (which is anxiolytic and sedative).

A lot has been said in this debate and a sort of misguided idea that has been floating around lately is that the therapeutic effects of cannabis are entirely due to CBD, but this is not the case. Current thinking is that the cannabinoid receptor type 1 -- CB1 -- is responsible for analgesic (anti-pain) and recreational properties, while CB2 is responsible for antiinflammatory effects; these are both targeted by THC, not CBD. CBD binds to a novel binding site GPR55 (iirc) and to 5-ht1a, which is believed to be partially responsible for the prosocial effects of MDMA, but not to cannabinoid receptors. Wrt. cancer, a bad summary is that THC activates some parts of the body's natural cancer defenses via CB2 (all CB2 agonists do so) and CBD might have some strange, mechanism-not-yet-determine antiproliferative activity. However, these effects may be too modest to be practically useful (who knows?); cancers easily become resistant to CB2 agonists.

While I'm blabbering I might as well dispense with the idea propounded by some that cannabis should only be used medically in the form of precisely calibrated extract compositions: this idea, while attractive, is simply too expensive, and unfair to poor people seeking pain relief, somnolescence, etc. However, from what I've seen here today, it might not be bad to try to implement a system where doctors can prescribe a specific terpenoid ratio w.r.t. THC, CBD, and THCV; the last is an antagonist and may give strains a "ceiling" effect, which can be useful if people need to smoke all day for some reason.

Indicas don't contain roughly equal amounts of THC and CBD -- the difference between the two is at least an order of magnitude. An exemplar indica might have 20% THC and 1.5% CBD, which would be considered an extremely high level of CBD. Your main point is still valid though, I just wanted to make the relative quantities clear.

Some nonspecific examples of tested strain concentration:


> An exemplar indica might have 20% THC and 1.5% CBD, which would be considered an extremely high level of CBD.



Many strains according to this site of yours certainly seem to contain significantly more than 1.5% CBD. Ditto this study:


... which doesn't include any modern US strains but provides strong support for the idea that there are plants with large amounts of both CBD and THC. I actually may have made a separate mistake...

>Elevated levels of CBDV and/or THCV were much more common in plants of C. indica than in plants of C. sativa. Plants with elevated levels of THCV, sometimes exceeding THC, were detected in all four biotypes of C. indica, but not in all accessions.

So my memory has failed me, or the common-wisdom I absorbed: Cannabis indica contains more of both THC and CBD than Cannabis sativa, but also contains larger amounts (and proportion) of the antagonist homologue THCV. And modern strains are all really hybrids anyway.

Hmm, to be honest, I've never encountered any strain above 1.5% or so CBD, so that takes me by surprise, a bit. I also have access to a fairly diverse selection of MMJ options in a permissive state, so I'm surprised I haven't seen any strains like that.

Learn something new every day, I suppose. I appreciate the info - I'll keep on the look out.

I've read studies about weed and pain relief. Brain scans still show the 'pain areas' of the brain are active in MS pateints, but patients themselves are generally less bothered by the pain, and it seems similar with opiates. Sometimes the opiates or other painkillers aren't enough to get rid of the pain, but if you aren't nearly as bothered by the pain that the painkiller didn't take care of, suddenly the pain is much more tolerable and you are more able to go on with life. For myself, I notice that sometimes this is the difference between being able to sleep with monthly pain and lying awake. Your reaction is unique: Some people do have bad reactions, and it could be that a different form (hashish, for example) will do the trick for you.

To me, It doesn't matter if the results are actual pain relief either. If it helps make it so the pain is tolerable so that one can function more normally, it really doesn't matter. Perceived improvement is good for the mind.

It seems like it is desirable for pain killers to leave the pain areas of our brain active, but make the pain less bothersome. If they worked by literally stopping the pain, then we would not notice if we were doing something that was injuring us.

This just shows that there is a link between marijuana and the feelings of pain (anecdotal evidence with sample size 1, but still). And the way you are describing it, it seems that it gives you 'ideas of pain' rather than pain itself, a subtle but important distinction. If this is the case, it is more aking to the way hypnosis reduces pain, rather than painkillers. Which makes sense, since marijuana does make a person a lot more suggestible, which can be used to the user's benefit if properly controlled.

In your particular case, might it be that you're hypnotising yourself into remembering and feeling old pain ?

I agree. To me weed has little influence on pain. OTC painkillers work better without a doubt - at least for the common sources of pain. Besides, the side effects (being high...) are such that even if it was efficient it still would be unusable most of the time.

OTC painkillers are almost useless for significant pain levels. Think levels of pain where coherent speach is basicly impossible without medication. Unfortunatly that's only about an 8 on the 1-10 pain scale.

For real pain there are several drugs that rather than just blocking the sensation tone down the importance of pain. Pot, falls into this group and relative to the benifit has few side effects.

Considering that pot doesn't help (me) with common pains such as headache, back pain, tooth pain, I'm led to believe it doesn't help either with extremely severe pain. Where there any scientific studies that tackle those questions?

I'm all in favour of legalisation, but the medical trend sounds like a big hypocrisy to me. I'm certain some patients benefit somehow from the effects of THC or CDB, but pretty much all cannabis users are recreational.

I used to vape for pain from nerve compression after I went through a couple of unsatisfying treatment options - and no otc painkillers even touch it so that's that. There's some studies and anecdata showing that pot is potentially helpful for neuropathic pain, which is a different and very hairy beast.

From my experience, it only tones down the sensation of pain at best, maybe just a placebo. More often I would just get high as a kite to stop caring about pain and/or to be able to sleep easily. Not that that's a bad thing but... in the end I tried another prescription option and get most of the same toning down/drowsiness effect without bad side effects for far cheaper, so that was the end of that.

No doubt many users just want to use it recreationally, but enough people are motivated to study medicinal uses, so that's good. I think there is some potential here for that.

Here's some links:

http://blog.sfgate.com/smellthetruth/2014/08/26/marijuana-va... http://www.webmd.com/pain-management/news/20080625/pot-may-e... http://www.webmd.com/pain-management/news/20100830/marijuana...

As sycthye alludes to, you should be looking at high-CBD strains for pain relief, not typically THC-heavy sativa strains.

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