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. Author manuscript; available in PMC: 2025 Dec 24.
Published in final edited form as: Milbank Q. 2025 Sep 8;103(Suppl 1):411–434. doi: 10.1111/1468-0009.70052

The impact of medical cannabis laws on cannabis and opioid use disorder treatment and overdose-related healthcare utilization among adults with chronic non-cancer pain

Emma E McGinty 1, Pradhyumna Wagle 1, Christie Lee Luo 1, Nicholas J Seewald 2, Elizabeth A Stuart 3, Kayla N Tormohlen 1
PMCID: PMC12673165  NIHMSID: NIHMS2119295  PMID: 40917076

Abstract

Context:

State medical cannabis laws, currently in place in 39 states and DC, provide an avenue for therapeutic use of cannabis to manage chronic non-cancer pain stemming from conditions such as arthritis and low back pain. These laws may also influence cannabis and opioid addiction and overdose, for example if people substitute cannabis in place of opioids to manage pain. No studies have examined how state medical cannabis laws influence healthcare utilization related to addiction to or overdose from cannabis or opioids among people with chronic non-cancer pain.

Methods:

We used a difference-in-differences design and augmented synthetic control analyses comparing changes in cannabis use disorder (CUD) and opioid use disorder (OUD) treatment and cannabis and opioid overdose-related healthcare utilization before and after medical cannabis law implementation among Medicare beneficiaries with chronic non-cancer pain in seven states (FL, MD, MN, NH, NY, OK, PA) relative to changes in outcomes over the same period in 17 (AL, GA, ID, IN, IA, KS, KY, MS, NE, NC, SC, SD, TN, TX, VA, WI, WY) comparison states without medical cannabis laws.

Findings:

State medical cannabis laws had an estimated average effect of less than 0.005 percentage points on the overall proportion of patients receiving any CUD or OUD treatment, less than 0.009 percentage points on the proportion of patients newly initiating CUD or OUD treatment, and less than 0.0005 percentage points on the proportion of patients receiving overdose-related healthcare for cannabis or opioid overdoses (p>0.05 for all findings).

Conclusions:

Our study did not identify effects of state medical cannabis laws on healthcare utilization related to CUD or OUD treatment or overdose among Medicare beneficiaries under the age of 65 with chronic non-cancer pain.

Keywords: Cannabis law, chronic pain, addiction, substance use disorder, cannabis use disorder, opioid use disorder

INTRODUCTION

State medical cannabis laws, currently in place in 39 states and DC, provide an avenue for therapeutic use of cannabis to manage chronic non-cancer pain stemming from conditions such as arthritis and low back pain.1 These laws may also impact cannabis use disorder (CUD) and overdose. An estimated three in every 10 people who use cannabis have CUD.2 Cannabis use can also lead to overdose, though cannabis overdose is very rarely fatal.3 On the other hand, there is potential for these laws to curb rates of opioid use disorder (OUD) and opioid overdose, by leading people to substitute cannabis in place of opioids for pain management. Despite the fact that medical cannabis laws are expected to influence opioid use via substitution of cannabis in place of opioids for pain management, no studies have examined how these state laws impact cannabis and opioid addiction and overdose among people with chronic non-cancer pain.

Nearly one-quarter of U.S. adults experience chronic non-cancer pain, defined as pain occurring most or every day in the past three months from conditions other than cancer.4 While prevalence of chronic non-cancer pain increases with age, affecting 36% of adults aged 65 years and older, it also impacts meaningful proportions of younger age groups: in 2023, 29% of U.S. adults ages 45–64, 18% ages 30–44, and 12% ages 18–29 reported experiencing chronic non-cancer pain meeting the definition above.4 Chronic pain non-cancer pain and opioid addiction commonly co-occur. In the overall U.S. adult population, an estimated 2–3% of adults have OUD.5 In comparison, estimates of OUD prevalence among adults with chronic non-cancer pain range from 8–34%; as no nationally representative data exists, prevalence estimates vary across study-specific samples.6 Chronic pain and addiction share underlying neurobiological mechanisms, making it challenging to disentangle cause and effect.7 In some cases, a person’s experience of chronic pain leads them to use, and subsequently develop addiction to, prescribed (e.g., prescription opioids) or non-prescribed (e.g., heroin, illicitly produced fentanyl) opioids for pain management.8,9

From the late 1990s-early 2010s, prescription opioids were clinically accepted first-line treatments for chronic non-cancer pain.10 Steep increases in rates of opioid overdose paralleling increases in opioid prescribing, and growing evidence of limited effectiveness for long-term pain management, led to shifts in clinical practice.11,12 Current clinical guidelines recommend conservative procedures (e.g., physical therapy) and non-opioid prescription medications (e.g., anticonvulsants) as first-line treatments for chronic non-cancer pain.12 While no clinical guidelines currently recommend cannabis, adults with chronic non-cancer pain view cannabis as equally effective and safer than prescription opioids for chronic pain management.13 A third of adults with chronic non-cancer pain living in states with medical cannabis laws report using cannabis to manage their pain, and more than half of those who use cannabis for pain report that their use of cannabis has led them to decrease prescription opioid use.14

No studies have examined how state medical cannabis laws influence healthcare utilization related to addiction or overdose from cannabis or opioids among people with chronic non-cancer pain. Studies using general population samples, which include people using cannabis for reasons other than management of chronic noncancer pain, generally point toward small increases in healthcare use for CUD and cannabis overdose attributable to the laws and mixed and inconclusive findings regarding laws’ impacts on OUD and opioid overdose.15–20

Our study assessed the effects of state medical cannabis laws on overall patterns of healthcare utilization for CUD or OUD treatment; new initiation of CUD or OUD treatment; and cannabis and opioid overdose-related healthcare among Medicare beneficiaries under the age of 65 with chronic non-cancer pain. As this population qualifies for Medicare due to disability and has high rates of chronic pain and substance use disorders, understanding how medical cannabis laws influence CUD treatment, OUD treatment, and cannabis and opioid-related overdose is highly salient for this group.21–24 Study of treatment initiation examines the laws’ potential effects on treatment for newly developed CUD or OUD following medical cannabis law implementation. Our study design and analytic approach overcomes methodological limitations of prior studies15 by limiting the sample to patients with chronic non-cancer pain and using a “stacked” difference-in-differences approach with augmented synthetic control analysis that together help to avoid biases that can result from traditional two-way-fixed effects difference-in-differences analyses of the staggered adoption of medical cannabis laws across states.25

METHODS

Design

We used a difference-in-differences design comparing changes in CUD and OUD treatment and overdose-related healthcare utilization before and after medical cannabis law implementation in seven states (FL, MD, MN, NH, NY, OK, PA) relative to changes in outcomes over the same period in 17 (AL, GA, ID, IN, IA, KS, KY, MS, NE, NC, SC, SD, TN, TX, VA, WI, WY) comparison states without medical cannabis laws. Each medical cannabis law state had a unique six-year study period encompassing three years before and three years after law implementation and a distinct comparison group comprised of patients from the 17 comparison states without medical cannabis laws who met eligibility criteria (see below) over the same six-year period. The earliest medical cannabis law state-specific study period started in July 2012 and the latest period ended in October 2021. We excluded states with laws legalizing cannabis for recreational use during the study period, as these laws could also influence cannabis- and opioid-related treatment and overdose if people with chronic non-cancer pain access cannabis via recreational, as opposed to medical, channels. The seven medical cannabis law and 17 comparison states were the states meeting these criteria between 2012–2021, the years of data available for the study.

Data

We used Medicare fee-for-service claims data from 2012–2021, which captured 100% of inpatient, outpatient, and pharmacy claims for patients enrolled in the traditional Medicare program during this period. We accessed the data via the Centers for Medicare and Medicaid Services (CMS) Virtual Research Data Center (VRDC). State medical cannabis law data was assembled using legal epidemiology strategies including systematic searches of the Westlaw database to identify statutes and regulations and identification of regulatory materials and state session laws.26 This legal research confirmed that chronic non-cancer pain was listed as a qualifying condition for medical cannabis use in the seven medical cannabis law states included in the study.

Analytic Sample

We constructed seven analytic samples, one for each medical cannabis law state and its comparison group, each with a unique six-year (three-year pre-law, three-year post-law) study period. We included adults under the age of 65 who were continuously enrolled in Medicare parts A (inpatient), B (outpatient) and D (pharmacy) in a given calendar year who had a diagnosis of a condition(s) commonly leading to chronic pain during in the three years prior to medical cannabis law implementation. Specifically, patients were included if they had one inpatient or two outpatient diagnosis codes (Appendix A) for conditions that commonly lead to chronic non-cancer pain including arthritis, low back pain, serious headache, fibromyalgia, or neuropathic pain;27–29 people meeting this criterion for multiple diagnoses were coded as having each condition. Patients who lived in two different states in a given year were excluded. As Medicaid-covered substance use treatment and overdose-related services for dual eligibles are not observable in Medicare data, beneficiaries dually receiving full Medicaid benefits were excluded.

Measures

Overall treatment utilization outcome measures included the proportion of patients with chronic non-cancer pain using any inpatient or outpatient services for CUD or OUD treatment. Treatment initiation measures included the proportion of patients with chronic non-cancer pain newly initiating treatment, defined as the first inpatient or outpatient CUD or OUD treatment claim in 60 days, per state per month. CUD and OUD overdose-related utilization were measured as the proportion of patients with an inpatient, outpatient, or ED overdose claim per state per month. All outcome measures were constructed at the patient-month level and aggregated to the state-month level for analyses. See appendix B for detailed measure specifications.

State medical cannabis laws were coded as binary indicators that changed from 0 to 1 in the first month that a law was implemented for 15 or more days (Appendix C). Consistent with prior work, medical cannabis law implementation was coded as starting on the day the first dispensary opened for business.30–32 Covariates were measured at the state-year level and included the proportion of patients who were female; the proportion who were non-Hispanic Black, non-Hispanic White, Hispanic, or other race/ethnicity; the proportion who had a mental illness diagnosis; and mean patient age per state per year.

Analysis

We used the augmented synthetic control approach, which is designed to create a “synthetic” comparison group that estimates the counterfactual of what would have happened in a state that implemented a law in the absence of that law.33 This method first weights comparison states so that average outcomes during the pre-law period are similar to those in the medical cannabis law-implementing state. Then, a difference-in-differences regression model is used to estimate the mean difference in change in outcomes before and after law implementation in the cannabis law-implementing state and its synthetic (weighted) comparison group. Because the weighting balances average pre-law outcomes in the medical cannabis law state and its synthetic comparison group, the first difference in the difference-in-differences is approximately zero. The policy effect, interpreted as the average treatment effect on the treated (ATT), is therefore the difference in outcomes between a law-implementing state and its synthetic comparison group in the post-law period. The augmented synthetic control approach makes several improvements over the standard synthetic control approach34 by “augmenting” the standard approach with a parametric outcome model to refine the weighting and test statistical significance.33

For each medical cannabis law state, we constructed a synthetic comparison group as the weighted average of the 17 comparison states without medical cannabis laws during the study period that best aligned with the medical cannabis law-implementing state’s magnitude of and trends in outcomes and covariates during the three-year pre-law period. We then refined the weights to equalize average pre-law outcomes in the two groups using a linear regression model that controlled for covariates and included state-fixed effects accounting for potential unobserved state-specific factors. As the weighting used to create the synthetic comparison group is outcome-specific, we repeated this approach for each outcome in each of the seven medical cannabis law states and their comparison groups.

The analyses described above produced state-specific estimates of the impact of each state’s medical cannabis law on each outcome. To estimate the average impact across states, we “stacked”25 the individual state estimates by calculating an inverse-variance weighted average of the state-specific estimates. To examine whether impacts may vary over time, we then estimated month-by-month changes in outcomes attributable to state medical cannabis law implementation. For all models, statistical significance was defined as p<0.05. Analyses were conducted in R Version 4.4.3. This study was approved by the Weill Cornell Medical College Institutional Review Board.

FINDINGS

Exhibit 1 shows the balance of patient characteristics and OUD and CUD treatment utilization in the medical cannabis law-implementing states and the weighted comparison states (the “synthetic controls”) in the three years prior to cannabis law implementation. The augmented synthetic control approach prioritizes equalizing pre-policy outcome measures in the treatment and comparison groups. The standardized mean differences (SMDs) between pre-law CUD and OUD treatment and cannabis and opioid overdose outcome measures in medical cannabis law states and weighted comparison states were zero, showing excellent balance. Covariates also had excellent balance, with SMDs below 0.2 in all but one case. The average pre-law proportion of patients with a mental illness diagnosis was 23.3 in treatment states and 21.1 in weighted comparison states, with a SMD of 0.695. In both treatment and weighted comparison states during the pre-law implementation periods used in augmented synthetic control analyses, 56% of patients were female and the mean age was 51 years. Fewer than 1% of patients with chronic non-cancer pain had healthcare utilization for CUD or OUD treatment or overdose care, on average, per month.

Exhibit 1.

Characteristics of patients in states that implemented medical cannabis laws and weighted comparison states in the three years1 prior to law implementation

Treatment states
N=7 states,
36,6092 individuals		 Weighted comparison states N=17 states, 29,5843 individuals Standardized Mean Difference4
Patient characteristics, per year (SE)
 % Female 56.1 (1.2) 55.8 (2.3) 0.117
 Race and ethnicity
  % non-Hispanic White 73.6 (0.4) 75.3(12.7) 0.132
  % non-Hispanic Black 15.7 (0.3) 15.9(9.1) 0.027
  % Hispanic 6.1 (0.2) 5.7 (8.1) 0.045
 % w/mental illness diagnosis 23.3 (2.6) 21.1 (3.1) 0.695
 Mean age 51.3 (1.9) 51.2 (2.0) 0.027
Overall treatment utilization, per month (SE)
 CUD
 % of patients with any inpatient CUD treatment 0.0032 (0.0008) 0.0032 (0.0003) 0.000000
 % of patients with any outpatient5 CUD treatment 0.032(0.001) 0.032 (0.001) 0.000000
 OUD
 % of patients with any inpatient OUD treatment 0.028 (0.002) 0.028 (0.001) 0.000000
 % of patients with any outpatient6 OUD treatment 0.76(0.02) 0.76(0.01) 0.000000
Treatment initiation, per month (SE)
 % of patients newly initiating CUD treatment 0.007 (0.0006) 0.007 (0.0004) 0.000000
 % of patients newly initiating OUD treatment 0.14 (0.005) 0.14 (0.004) 0.000000
Overdose, per month (SE)
 % of patients with any CUD overdose utilization 0.007 (0.0005) 0.007 (0.0003) 0.000000
 % of patients with any OUD overdose utilization 0.08 (0.004) 0.08 (0.003) 0.000000
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1

The three calendar years before law implementation vary for each of the seven medical cannabis law states and its comparison group of 17 states without a medical cannabis law from 2012–2021. This table shows characteristics of patients averaged across the seven unique pre-law periods.

2

Average number of enrolled beneficiaries per year across all treatment states.

3

Average number of enrolled beneficiaries per year across all comparison states.

4

Standardized mean differences is the number of standard deviations between the groups’ means using the standard deviation of the comparison states as the denominator.

In a given month during the three years before law implementation in the states that implemented medical cannabis laws and their synthetic comparison groups, an estimated average 0.003% of patients had inpatient CUD treatment; 0.03% had outpatient CUD treatment; 0.03% had inpatient OUD treatment; and 0.76% had outpatient OUD treatment. In a given month during the three years following law implementation, medical cannabis law states had average estimated changes of −0.0002, −0.004, −0.004, and 0.22 percentage points in inpatient CUD treatment, outpatient CUD treatment, inpatient OUD treatment, and outpatient OUD treatment, relative to 0.0007, −0.005, −0.0005, and 0.22 percentage point changes in the same outcomes in the synthetic weighted comparison group. This translates into average differences of −0.0009 (95% CI: −0.006, 0.004); 0.0008 (95% CI: −0.007, 0.009); −0.004 (95% CI: −0.01, 0.004); and 0.005 (95% CI: −0.08, 0.09) in the proportion of patients receiving any inpatient CUD treatment, outpatient CUD treatment, inpatient OUD treatment, or outpatient OUD treatment attributable to state medical cannabis laws. Exhibit 2 shows the month-by-month changes in the outcomes of interest in the proportion of patients with chronic non-cancer pain receiving any inpatient or outpatient CUD or OUD treatment attributable to state medical cannabis laws. As suggested by the estimated monthly change in CUD and OUD treatment utilization outcomes averaged over the three-year post-law period above, Exhibit 2 shows similar magnitude of these outcomes in medical cannabis law and synthetic comparison states in each month following law implementation.

Exhibit 2.

Exhibit 2.

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Proportion of patients with chronic non-cancer pain receiving any cannabis use disorder (CUD) or opioid use disorder (OUD) treatment, in a given month, in medical cannabis law and comparison states.

Notes: These graphs depict the mean monthly proportion of patients with chronic non-cancer pain receiving inpatient or outpatient CUD or OUD treatment in each month included in the augmented synthetic control analyses. Shading in the post-policy period indicates 95% confidence intervals. Treatment states are defined as states with medical cannabis laws (FL, MD, MN, NH, NY, OK PA) and comparison states are states without medical cannabis laws (AL, GA, ID, IN, IA, KS, KY, MS, NE, NC, SC, SD, TN, TX, VA, WI, WY). The augmented synthetic control approach weights the comparison states to make them as similar as possible to treatment states on pre-policy outcomes and covariates, creating a “synthetic control.”

There was similar magnitude in the proportion of patients with chronic non-cancer pain initiating CUD or OUD treatment (Exhibit 3) and receiving inpatient or ED treatment for cannabis or opioid overdose (Exhibit 4) in each month before and after medical cannabis law implementation in law-implementing states. In a given month during the three years prior to law implementation, an estimated average 0.007 and 0.14% of patients with no CUD or OUD treatment in the past six months newly initiated CUD or OUD treatment. In a given month during the three years after law implementation, medical cannabis law states had estimated average changes of −0.00003 and 0.06 percentage points in CUD or OUD treatment initiation, relative to 0.0009 and 0.05 percentage point increases in synthetic comparison states. This translates into average differences of −0.001 (95% CI: −0.004, 0.003) and 0.009 (95% CI: −0.03, 0.04) in the proportion of patients newly initiating CUD or OUD treatment attributable to state medical cannabis laws.

Exhibit 3.

Exhibit 3.

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Proportion of patients with chronic non-cancer pain newly initiating cannabis use disorder (CUD) or opioid use disorder (OUD) treatment, in a given month, in medical cannabis law and comparison states.

Notes: These graphs depict the mean monthly proportion of patients with chronic non-cancer pain initiating CUD or OUD treatment in each month included in the augmented synthetic control analyses. Shading in the post-policy period indicates 95% confidence intervals. Treatment states are defined as states with medical cannabis laws (FL, MD, MN, NH, NY, OK PA) and comparison states are states without medical cannabis laws (AL, GA, ID, IN, IA, KS, KY, MS, NE, NC, SC, SD, TN, TX, VA, WI, WY). The augmented synthetic control approach weights the comparison states to make them as similar as possible to treatment states on pre-policy outcomes and covariates, creating a “synthetic control.”

Exhibit 4.

Exhibit 4.

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Proportion of patients with cannabis use disorder (CUD) or opioid use disorder (OUD) overdose-related healthcare utilization, in a given month, in medical cannabis law and comparison states.

Notes: These graphs depict the mean monthly proportion of patients with chronic non-cancer pain receiving CUD or OUD overdose-related treatment in each month included in the augmented synthetic control analyses. Shading in the post-policy period indicates 95% confidence intervals. Treatment states are defined as states with medical cannabis laws (FL, MD, MN, NH, NY, OK PA) and comparison states are states without medical cannabis laws (AL, GA, ID, IN, IA, KS, KY, MS, NE, NC, SC, SD, TN, TX, VA, WI, WY). The augmented synthetic control approach weights the comparison states to make them as similar as possible to treatment states on pre-policy outcomes and covariates, creating a “synthetic control.”

For overdose, an estimated average 0.007% of patients with chronic non-cancer pain had inpatient or ED utilization related to cannabis overdose and an estimated average 0.08% had utilization related to opioid overdose in the three years before medical cannabis law states implemented their laws. In a given month over the three years following implementation, medical cannabis law states had −0.0003 and 0.01 percentage point changes in cannabis or opioid overdose-related utilization relative to −0.0009 and 0.02 percentage point changes in weighted comparison states. Thus, average differences of 0.0005 (95% CI: −0.003, 0.003) and −0.003 (95% CI: −0.02, 0.01) in the proportion of patients with cannabis or opioid overdose-related overdose were attributable to implementation of medical cannabis laws. State-specific results for each outcome are shown in appendix D. Results were consistent with the findings presented above. No changes in outcomes attributable to medical cannabis laws were statistically significant at the p<0.05 level.

CONCLUSIONS

Our study did not identify effects of state medical cannabis laws on healthcare utilization related to CUD or OUD treatment or overdose among Medicare beneficiaries under the age of 65 with chronic non-cancer pain. State medical cannabis laws had an estimated average effect of less than 0.005 percentage points on the overall proportion of patients receiving any CUD or OUD treatment, less than 0.009 percentage points on the proportion of patients newly initiating CUD or OUD treatment, and less than 0.0005 percentage points on the proportion of patients receiving overdose-related healthcare for cannabis or opioid overdoses. For all measures, confidence intervals were narrow, not exceeding a 0.09 percentage point increase or decrease.

In surveys, adults with chronic non-cancer pain report substituting cannabis in place of prescription opioids for pain management.14,35,36 However, our findings suggest that state medical cannabis laws did not lead to such substitution with enough frequency or intensity to influence population-level use of treatment for cannabis or opioid addiction or overdose. This finding is consistent with a prospective cohort study showing that cannabis use was not associated with changes in future prescription opioid use among patients with chronic non-cancer pain.37

Previous research using cross-sectional, general population samples has suggested that medical cannabis laws may decrease prescription opioid use,38–45 which we would expect to lead to decreases in treatment for OUD and overdose. However, more recent work using a longitudinal cohort of chronic non-cancer pain patients found no effects of state medical cannabis laws on opioid prescription receipt, dose, or duration.46 This suggests that the results of prior studies may be influenced by inclusion of people without chronic noncancer pain the sample who use opioids for acute pain. State opioid prescribing laws implemented at or around the same time as many medical cannabis laws have been shown to reduce opioid prescribing for acute,47–50 but not chronic non-cancer,51,52 pain. Despite heightened attention to the problem of poor pain management in the 1990s – driven in part by the “pain as the 5th vital sign” concept disseminated by the American Pain Society53 – the prevalence of chronic non-cancer pain remains high.4,54 Rapid increases in opioid prescribing for chronic non-cancer pain beginning in the late 1990s and early 2000s were a key driver of the ongoing opioid overdose crisis in the U.S. and simultaneously failed to improve pain management at the population level,55,56 with evidence suggesting that long-term prescription opioid use can increase pain sensitivity among some patients.57 Proponents view medical cannabis laws as part of the solution to poor chronic pain management, but the evidence on the safety and effectiveness of cannabis for chronic non-cancer pain is limited and subject to varying interpretations. In separate publications, the National Academies of Sciences, Engineering and Medicine (NASEM) and the Cochrane Library reviewed largely identical bodies of evidence and came to disparate conclusions, with the NASEM concluding that there was substantial evidence supporting the effectiveness of cannabis for treatment of chronic pain3 and the Cochrane review concluding that the benefits of cannabis for chronic neuropathic pain might be outweighed by harms.58 Our findings suggest that medical cannabis laws did not result in cannabis or opioid addiction or overdose related harms among Medicare beneficiaries with chronic non-cancer pain.

Study findings should be interpreted in the context of several limitations. Causal inference in this observational study depends upon the untestable assumption that in the absence of medical cannabis law implementation, trends in outcomes in medical cannabis law states would have followed the same trajectory as trends in outcomes in the synthetic comparison group. Unmeasured confounders could bias our results, but in the difference-in-differences context such confounders would have to systematically vary across states implementing medical cannabis laws and comparison states not implementing those laws and over time.59 The finite number of states available for analysis limits statistical power, but consistently small effect estimates and narrow confidence intervals lessen concerns that lack of observed effects was due to inadequate power. Our study’s use of administrative claims data precluded measurement of patients’ use of cannabis or non-prescribed opioids. Finally, our study did not capture cannabis or opioid overdoses that did not receive treatment in the ED or hospital settings.

In conclusion, this study was the first to examine the impact of state medical cannabis laws on healthcare use related to cannabis or opioid addiction or overdose among a large population of adults with chronic noncancer pain. Study findings did not identify impacts of these laws on the addiction and overdose treatment outcomes examined among adults under the age of 65 with a condition(s) commonly leading to chronic non-cancer pain who qualified for Medicare due to disability.

Supplementary Material

Appendix

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Appendix
NIHMS2119295-supplement-Appendix.docx (806.1KB, docx)

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