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Co-use of cannabis and prescription opioids in adults in the USA: a population-based, cross-sectional analysis of the NHANES from 2009 to 2018
  1. Calvin Diep1,
  2. Akash Goel1,2,
  3. Duminda N Wijeysundera1,2,
  4. Hance Clarke1,3 and
  5. Karim S Ladha1,2
  1. 1Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
  2. 2Department of Anesthesia, St Michael's Hospital, Toronto, Ontario, Canada
  3. 3Department of Anesthesia and Pain Medicine, University Health Network, Toronto, Ontario, Canada
  1. Correspondence to Dr Karim S Ladha, Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada; karim.ladha{at}


Introduction Cannabis and cannabinoids continue to gain popularity as adjuncts or alternatives to opioids in pain management, with evolving evidence of effectiveness. The relationship between cannabis and opioid use has previously been investigated in smaller cohorts or ecological samples, but not yet in a nationally representative sample.

Methods A cross-sectional analysis of adults in the USA was undertaken using National Health and Nutrition Examination Survey (NHANES) data from 2009 to 2018. The primary exposure was self-reported use of at least one opioid-containing prescription medication in the 30 days prior to survey administration. The outcome of interest was self-reported cannabis use in the same period. Multivariable logistic regression was used to adjust for sociodemographic and health-related covariates, and NHANES survey sample weights were included in modeling. Prescription opioid users were then subclassified as short-term users (<90 days) or chronic users (≥90 days) in secondary analysis.

Results A total 10,928 survey respondents were included in analyses, representing 110 million adults in the USA aged 18–59. In this weighted cohort, 5.6%±0.4% reported a recent opioid prescription. Among prescription opioid users, 18.4%±3.1% reported recent cannabis use, not significantly different from 17.7%±0.7% among non-users (OR 1.05, 95% CI 0.81 to 1.36, p=0.714). After adjustment for covariates, opioid users were significantly less likely to have recently used cannabis (adjusted OR, aOR 0.70, 95% CI 0.51 to 0.97, p=0.032). When opioid users were subclassified by duration of prescription, there was no detectable difference in recent cannabis use between chronic opioid users and short-term opioid users (aOR 1.11, 95% CI 0.70 to 1.78, p=0.649).

Conclusion Recent prescription opioid use was associated with decreased odds of cannabis use in this cross-sectional analysis of a nationally representative cohort. These findings suggest that use of cannabis or prescription opioids may not independently promote use of the other.

  • analgesics, opioid
  • epidemiology
  • outcome assessment, health care

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  • Twitter @calvdiep, @AkashGoelMD, @PinnaclePeriop, @drhaclarke, @drladha

  • Contributors CD and KSL designed the study. CD and KSL obtained, coded, and analyzed the data. CD, AG, DNW, HC, and KSL prepared the manuscript. KSL accepted responsibility for the conduct, content, and publication of this study as guarantor.

  • Funding DNW, HC, and KSL are supported in part by Merit Awards from the Department of Anesthesiology and Pain Medicine at the University of Toronto (Toronto, Canada). DNW is supported in part by the Endowed Chair in Translational Anesthesiology Research at St. Michael’s Hospital (Toronto, Canada) and the University of Toronto (Toronto, Canada).

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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