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      The impact of cannabis use on patients enrolled in opioid agonist therapy in Ontario, Canada

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          Abstract

          Background

          With the Canadian government legalizing cannabis in the year 2018, the potential harms to certain populations—including those with opioid use disorder—must be investigated. Cannabis is one of the most commonly used substances by patients who are engaged in medication-assisted treatment for opioid use disorder, the effects of which are largely unknown. In this study, we examine the impact of baseline and ongoing cannabis use, and whether these are impacted differentially by gender.

          Methods

          We conducted a retrospective cohort study using anonymized electronic medical records from 58 clinics offering opioid agonist therapy in Ontario, Canada. One-year treatment retention was the primary outcome of interest and was measured for patients who did and did not have a cannabis positive urine sample in their first month of treatment, and as a function of the proportion of cannabis-positive urine samples throughout treatment.

          Results

          Our cohort consisted of 644 patients, 328 of which were considered baseline cannabis users and 256 considered heavy users. Patients with baseline cannabis use and heavy cannabis use were at increased risk of dropout (38.9% and 48.1%, respectively). When evaluating these trends by gender, only female baseline users and male heavy users are at increased risk of premature dropout.

          Interpretation

          Both baseline and heavy cannabis use are predictive of decreased treatment retention, and differences do exist between genders. With cannabis being legalized in the near future, physicians should closely monitor cannabis-using patients and provide education surrounding the potential harms of using cannabis while receiving treatment for opioid use disorder.

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          Most cited references28

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          Medical cannabis laws and opioid analgesic overdose mortality in the United States, 1999-2010.

          Opioid analgesic overdose mortality continues to rise in the United States, driven by increases in prescribing for chronic pain. Because chronic pain is a major indication for medical cannabis, laws that establish access to medical cannabis may change overdose mortality related to opioid analgesics in states that have enacted them.
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            Medical Cannabis Use Is Associated With Decreased Opiate Medication Use in a Retrospective Cross-Sectional Survey of Patients With Chronic Pain.

            Opioids are commonly used to treat patients with chronic pain (CP), though there is little evidence that they are effective for long term CP treatment. Previous studies reported strong associations between passage of medical cannabis laws and decrease in opioid overdose statewide. Our aim was to examine whether using medical cannabis for CP changed individual patterns of opioid use. Using an online questionnaire, we conducted a cross-sectional retrospective survey of 244 medical cannabis patients with CP who patronized a medical cannabis dispensary in Michigan between November 2013 and February 2015. Data collected included demographic information, changes in opioid use, quality of life, medication classes used, and medication side effects before and after initiation of cannabis usage. Among study participants, medical cannabis use was associated with a 64% decrease in opioid use (n = 118), decreased number and side effects of medications, and an improved quality of life (45%). This study suggests that many CP patients are essentially substituting medical cannabis for opioids and other medications for CP treatment, and finding the benefit and side effect profile of cannabis to be greater than these other classes of medications. More research is needed to validate this finding.
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              Treatment retention among patients randomized to buprenorphine/naloxone compared to methadone in a multi-site trial.

              To examine patient and medication characteristics associated with retention and continued illicit opioid use in methadone (MET) versus buprenorphine/naloxone (BUP) treatment for opioid dependence. This secondary analysis included 1267 opioid-dependent individuals participating in nine opioid treatment programs between 2006 and 2009 and randomized to receive open-label BUP or MET for 24 weeks. The analyses included measures of patient characteristics at baseline (demographics; use of alcohol, cigarettes and illicit drugs; self-rated mental and physical health), medication dose and urine drug screens during treatment, and treatment completion and days in treatment during the 24-week trial. The treatment completion rate was 74% for MET versus 46% for BUP (P < 0.01); the rate among MET participants increased to 80% when the maximum MET dose reached or exceeded 60 mg/day. With BUP, the completion rate increased linearly with higher doses, reaching 60% with doses of 30-32 mg/day. Of those remaining in treatment, positive opioid urine results were significantly lower [odds ratio (OR) = 0.63, 95% confidence interval (CI) = 0.52-0.76, P < 0.01] among BUP relative to MET participants during the first 9 weeks of treatment. Higher medication dose was related to lower opiate use, more so among BUP patients. A Cox proportional hazards model revealed factors associated with dropout: (i) BUP [versus MET, hazard ratio (HR) = 1.61, CI = 1.20-2.15], (ii) lower medication dose (<16 mg for BUP, <60 mg for MET; HR = 3.09, CI = 2.19-4.37), (iii) the interaction of dose and treatment condition (those with higher BUP dose were 1.04 times more likely to drop out than those with lower MET dose, and (iv) being younger, Hispanic and using heroin or other substances during treatment. Provision of methadone appears to be associated with better retention in treatment for opioid dependence than buprenorphine, as does use of provision of higher doses of both medications. Provision of buprenorphine is associated with lower continued use of illicit opioids. © 2013 Society for the Study of Addiction.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: InvestigationRole: MethodologyRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: SupervisionRole: Writing – review & editing
                Role: ConceptualizationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Software
                Role: ConceptualizationRole: InvestigationRole: MethodologyRole: ResourcesRole: SupervisionRole: ValidationRole: VisualizationRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                8 November 2017
                2017
                : 12
                : 11
                : e0187633
                Affiliations
                [1 ] Northern Ontario School of Medicine, Sudbury, Ontario, Canada
                [2 ] Canadian Addiction Treatment Centers, Richmond Hill, Ontario, Canada
                Waseda University, JAPAN
                Author notes

                Competing Interests: The authors have no conflicts to disclose. Dr. David Marsh maintains the following roles: Chief Medical Director at CATC, opioid agonist therapy provider, and Associate Dean of Community Engagement and Deputy Dean of the Northern Ontario School of Medicine. Dr. Marsh has no ownership stake in the CATC as a stipendiary employee. We do not foresee any conflict of interest as data will be made freely available to the public and the CATC, and the Universities have no ability to prevent publication and dissemination of knowledge. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

                Author information
                http://orcid.org/0000-0002-8769-1785
                Article
                PONE-D-17-26540
                10.1371/journal.pone.0187633
                5678697
                29117267
                9fccc305-e8c6-4278-ad6e-e344e9249690
                © 2017 Franklyn et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 14 July 2017
                : 23 October 2017
                Page count
                Figures: 2, Tables: 1, Pages: 11
                Funding
                This study was funded by a Clinical Innovation Grant from the Northern Ontario Academic Medicine Association. JKE received funding as a successful recipient of the 2014-2015 CANOC Scholarship Awards Programme; (this programme is supported through the Centres Grant [CIHR 711314]). CANOC is funded by the Canadian Institutes of Health Research (CIHR) through a Centres Grant (Centres for HIV/AIDS Population Health and Health Services Research [CIHR 711314]); two Operating Grants (HIV/AIDS Priority Announcement [CIHR 711310]; Population and Public Health [CIHR 711319]); the CIHR Canadian HIV Trials Network [CTN 242]; and a Foundation Grant (Expansion of Antiretroviral Therapy and its Impact on Vulnerable Populations in Canada and Global Settings [CIHR # 143342]).
                Categories
                Research Article
                Medicine and Health Sciences
                Pharmacology
                Behavioral Pharmacology
                Recreational Drug Use
                Cannabis
                Biology and Life Sciences
                Anatomy
                Body Fluids
                Urine
                Medicine and Health Sciences
                Anatomy
                Body Fluids
                Urine
                Biology and Life Sciences
                Physiology
                Body Fluids
                Urine
                Medicine and Health Sciences
                Physiology
                Body Fluids
                Urine
                Biology and Life Sciences
                Psychology
                Addiction
                Addicts
                Drug Users
                Social Sciences
                Psychology
                Addiction
                Addicts
                Drug Users
                People and places
                Geographical locations
                North America
                Canada
                Ontario
                Medicine and Health Sciences
                Pharmacology
                Drugs
                Analgesics
                Opioids
                Medicine and Health Sciences
                Pain Management
                Analgesics
                Opioids
                Medicine and Health Sciences
                Pharmacology
                Drugs
                Opioids
                People and places
                Geographical locations
                North America
                Canada
                People and Places
                Population Groupings
                Professions
                Medical Personnel
                Medical Doctors
                Physicians
                Medicine and Health Sciences
                Health Care
                Health Care Providers
                Medical Doctors
                Physicians
                Medicine and Health Sciences
                Pharmaceutics
                Drug Therapy
                Custom metadata
                The dataset used in this study belongs to the health information custodian at the OATC, 13291 Yonge St., Ste. 403. Richmond Hill, Ontario L4E 4L6 and the Institute for Clinical and Evaluative Sciences, 2075 Bayview Ave, Toronto, ON M4N 3M5. The data is available through the Institute for Clinical and Evaluative Sciences (ICES). The health administrative databases used in this study are collected by and under the custody and control of the Ontario Ministry of Health and Long-Term Care, Canadian Institute for Health Information, Statistics Canada, and the Canadian Addiction Treatment Centers. The data were accessed at the Institute for Clinical Evaluative Sciences (ICES). Research services (i.e., Data Analytic Service http://www.ices.on.ca/DAS) exist at ICES through which interested external researchers can access ICES data for research purposes

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