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Inj Epidemiol. 2019 Sep 2;6:38. doi: 10.1186/s40621-019-0213-z. eCollection 2019.

State marijuana laws and opioid overdose mortality.

Chihuri S1,2, Li G1,2,3.

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1Center for Injury Epidemiology and Prevention, Columbia University Irving Medical Center, 622 West 168th St, PH5-505, New York, NY 10032 USA.
2Department of Anesthesiology, Columbia University College of Physicians and Surgeons, 622 West 168th St, PH5-505, New York, NY 10032 USA.
3Department of Epidemiology, Columbia University Mailman School of Public Health, 622 West 168th St, PH5-505, New York, NY 10032 USA.



The opioid epidemic in the United States is a national public health crisis. In recent years, marijuana legalization has been increasingly adopted by state governments as a policy intervention to control the opioid epidemic under the premise that marijuana and opioids are substitutive substances. The purpose of this systematic review is to synthesize the empirical evidence regarding the impact of state marijuana laws on opioid overdose mortality and other opioid-related health outcomes.


A comprehensive search of the research literature in 18 bibliographic databases returned 6640 records, with 5601 abstracts reviewed, 29 full text articles screened for eligibility, and 16 eligible studies included in the systematic review. Comprehensive Meta-Analysis software was used to generate summary estimates, forest plots, funnel plots, and heterogeneity statistics.


Of the 16 eligible studies, 4 assessed the association of state marijuana law status with opioid overdose mortality, 7 with prescription opioids dispensed, and the remaining with nonmedical use and opioid-related hospitalizations. Random effects modeling based on pooled data revealed that legalizing marijuana for medical use was associated with a statistically non-significant 8% reduction in opioid overdose mortality (95% confidence interval: - 0.21 to 0.04; p = 0.201) and a 7% reduction in prescription opioids dispensed (95% confidence interval: - 0.13 to - 0.01; p = 0.017). Legalizing marijuana for recreational use was associated with an additional 7% reduction in opioid overdose mortality in Colorado and 6% reduction in opioid prescriptions among fee-for-service Medicaid and managed care enrollees.


Legalizing marijuana might contribute to a modest reduction in opioid prescriptions. Evidence about the effect of marijuana legalization on opioid overdose mortality is inconsistent and inconclusive. If any, the effectiveness of state marijuana laws in reducing opioid overdose mortality appears to be rather small and limited to states with operational marijuana dispensaries. It remains unclear whether the presumed benefit of legalizing marijuana in reducing opioid-related harms outweighs the policy's externalities, such as its impact on mental health and traffic safety.


Cannabis; Drug overdose; Drug policy; Marijuana legalization; Opioid epidemic

Conflict of interest statement

Competing interestsGL is Editor-in-Chief of Injury Epidemiology. He was not involved in the peer-review or handling of the manuscript. The authors have no other competing interests to disclose.

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