The research team, led by Zachary L. Mannes of Columbia University Irving Medical Center and Deborah S. Hasin of Columbia University and the New York State Psychiatric Institute, focused on VHA patients aged 18 to 75 with chronic pain diagnoses. Veterans are a population of particular interest in this debate because chronic pain is among the most common conditions treated in the VA system, and the department has spent more than a decade working to reduce opioid exposure among its enrollees. The VA reports having cut the number of veterans prescribed opioids dramatically since 2012, through initiatives such as the Opioid Safety Initiative and updated clinical practice guidelines that emphasize non-opioid pain management. Against that backdrop, any independent effect of state cannabis policy is difficult to detect, which makes the new study’s methods especially important.

To isolate the effect of legalization from these broader secular trends, the investigators used staggered-adoption difference-in-difference models, a technique that has become the workhorse of modern policy evaluation. Because different states legalized medical cannabis and recreational cannabis at different times, the researchers could compare prescribing outcomes within the same patients and states before and after each law took effect, using states without such laws as the comparison group. States were categorized each year as having no medical or recreational cannabis law, a medical cannabis law only, or both. This approach controls for fixed characteristics of states and for national trends in opioid prescribing, such as the prescribing declines that followed the 2016 CDC opioid guideline, leaving the change associated with legalization itself.

The outcomes the team tracked were carefully chosen to capture different dimensions of opioid risk. They examined whether patients received at least 30 days of prescription opioids, whether they were on long-term opioid therapy, defined as at least 90 consecutive days of opioid supply without a gap of more than 15 days, whether they received high-dose opioids of at least 50 morphine milligram equivalents per day, and whether opioids were co-prescribed with benzodiazepines, a combination strongly linked to overdose death. Each of these measures reflects a distinct clinical decision point, from initiating an opioid prescription to escalating dose or layering on a sedative, and each has been flagged in national guidelines as a marker of potentially hazardous prescribing.

The results paint a nuanced picture. Enactment of a medical cannabis law was associated with a reduction of 0.79 percentage points in the share of patients receiving at least 30 days of opioids, and a reduction of 0.34 percentage points in long-term opioid therapy, relative to states without such laws. Those numbers may sound small, but applied across the enormous VHA population with chronic pain, they translate into thousands of patients shifting away from extended opioid courses. Notably, however, medical cannabis laws were associated with slight increases in the other two risk markers: high-dose opioid prescribing rose by 0.09 percentage points and opioid-benzodiazepine co-prescribing rose by 0.11 percentage points, changes the authors interpret cautiously given their small magnitude.

The story changed when recreational cannabis laws entered the picture. Following the enactment of recreational legalization, on top of existing medical laws, the researchers observed further declines in at least 30-day opioid prescribing, with an additional reduction of 0.14 percentage points, and more substantial drops in the two high-risk markers. High-dose opioid prescribing fell by 0.33 percentage points and opioid-benzodiazepine co-prescribing fell by 0.33 percentage points compared with the period after medical legalization alone. In other words, the transition from medical-only to full legalization was associated not just with less opioid prescribing overall, but with less of the kind of prescribing most closely tied to overdose risk, a pattern that runs counter to fears that wider cannabis availability would compound dangerous drug combinations.

Age emerged as a critical modifier of these effects. The associations between cannabis laws and opioid prescribing were generally more consistent among adults aged 65 to 75, the oldest group in the cohort. This finding is striking given that cannabis use has been rising fastest among older Americans in recent years, and given that older adults face elevated risks from both opioids and benzodiazepines due to altered drug metabolism, falls, and respiratory depression. If legal cannabis access is substituting for opioids anywhere, the data suggest it may be among older veterans with chronic pain, a group in whom clinicians may be particularly motivated to taper high-risk regimens when an alternative becomes legally available.

The authors are careful about what these associations do and do not mean. Difference-in-difference estimates capture population-level changes in prescribing, not individual decisions, and the study cannot confirm that any specific patient replaced an opioid with cannabis. The plausible mechanism, the researchers suggest, involves changes in both patient and clinician treatment decisions: patients in legal states may request cannabis as part of their pain management, and clinicians may feel more comfortable tapering opioids when patients have a sanctioned alternative. Survey evidence has long shown that chronic pain is the leading qualifying condition for medical cannabis licenses, and prior studies in Medicare and Medicaid populations have reported similar directional findings, though the literature overall has been mixed, with some studies finding no effect or effects concentrated in specific subgroups.

The study also arrives amid ongoing scientific uncertainty about whether cannabis actually relieves chronic pain. Randomized trials and meta-analyses of cannabinoids for chronic non-cancer pain have produced modest and inconsistent evidence of benefit, and recent best-practice advice from the American College of Physicians acknowledges both the limited efficacy data and the potential harms of cannabis use. Previous work by some of the same researchers found that cannabis legalization was associated with increases in cannabis use disorder diagnoses among VHA patients with chronic pain, a reminder that expanded access carries its own risks. The new findings therefore do not settle whether cannabis is an effective analgesic; they document a shift in prescribing behavior that accompanies legalization, whatever its underlying cause.

What the study does offer is the most comprehensive picture to date of how cannabis policy intersects with opioid care in the largest integrated health system in the United States. By following VHA patients through a decade in which the legal landscape transformed state by state, and by separating medical from recreational laws and dissecting prescribing into clinically meaningful risk categories, the research moves the debate beyond anecdote. The message for policymakers is measured: greater legal cannabis access appears associated with modest reductions in opioid prescriptions for chronic pain, particularly long-term therapy and, after recreational legalization, high-risk prescribing patterns, while the clinical question of whether cannabis should be recommended for pain remains open. As more states reconsider their cannabis laws, studies like this one will be essential for weighing the trade-offs embedded in those decisions.

Subject of Research: Association between state cannabis legalization and opioid prescribing patterns among veterans with chronic pain

Article Title: Cannabis Legalization and Opioid Prescribing in Veterans Health Administration Patients: 2013–2022

Article References: Mannes, Z. L., Wall, M. M., Stohl, M., Malte, C. A., Olfson, M., Livne, O., Fink, D. S., Simpson, T., Wisell, C. G., Keyhani, S., Martins, S. S., Cerdá, M., Sacco, D. L., Gutkind, S., Maynard, C. C., Sherman, S., Saxon, A. J., & Hasin, D. S. (2026). Cannabis Legalization and Opioid Prescribing in Veterans Health Administration Patients: 2013–2022. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10733-8

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10733-8

Keywords: cannabis legalization, opioid prescribing, chronic pain, Veterans Health Administration, medical cannabis law, recreational cannabis law, long-term opioid therapy, benzodiazepine co-prescribing, difference-in-difference, older adults, pain management, public health policy

The study, led by Benjamin J. Morasco of the VA Portland Health Care System and Oregon Health & Science University, drew its data from the Veterans’ Pain Care Organizational Improvement Comparative Effectiveness study, known as VOICE. That parent trial was a multisite, twelve-month randomized comparative effectiveness trial designed to test two real-world implementations of collaborative care for chronic pain, a model in which primary care teams work with specialized consultants to manage patients’ conditions systematically rather than leaving each clinician to improvise. Participants were randomized to one of two interventions that differed in resource intensity: an intensive interdisciplinary pain team, or a less resource-intensive pharmacist-led collaborative management approach. Both arms were grounded in the same collaborative care architecture, and both were delivered within the routine operations of the Veterans Health Administration, which is precisely what makes the trial pragmatic rather than a test of an idealized clinic that exists only in research settings.

For the secondary analysis, the research team collapsed the two treatment conditions and asked a different question than the original trial: did baseline substance use disorder status predict how patients fared? The answer required first establishing who carried that status. Of the 778 participants enrolled, 250, or 32.1 percent, met criteria for potential substance use disorder at baseline. That figure is striking in its own right, and it aligns with a broader literature documenting that roughly one in three patients on long-term opioid therapy for chronic pain has co-occurring substance use disorder. Epidemiological studies across health systems, including analyses of Norwegian health registries and large electronic health record datasets, have repeatedly found elevated rates of substance use diagnoses among chronic pain patients prescribed opioids, making this population impossible to ignore in any serious effort to improve opioid prescribing.

The demographic and clinical profile of the two groups differed in ways that matter for interpretation. Participants with potential substance use disorder were younger and more likely to have co-occurring mental health diagnoses than participants without it. Yet, critically, the groups showed no differences at baseline in pain interference, pain intensity, or prescription opioid dose. This baseline equivalence is methodologically important: it means that any divergence in outcomes during the trial could plausibly be attributed to substance use disorder status rather than to the groups starting from different levels of pain or different opioid exposures. The researchers measured pain using validated instruments, including the Brief Pain Inventory, which captures both the intensity of pain and the degree to which it interferes with daily functioning, a distinction that has become central to modern pain outcome assessment because interference often responds to treatment even when raw intensity does not fully remit.

The twelve-month results were unambiguous. Participants in both the potential substance use disorder group and the no-disorder group achieved statistically significant reductions in pain interference and pain intensity, alongside reductions in prescription opioid dose. In adjusted analyses that accounted for the demographic and clinical differences between groups, there was no difference between the groups in the magnitude of change on any of these outcomes. In other words, substance use disorder status did not blunt the response to collaborative care, did not prevent opioid dose reduction, and did not leave patients with more residual pain than their peers. For a population often excluded from trials or treated as a special case requiring separate pathways, this is a consequential null finding, in the best sense of the term.

The technical significance of this result becomes clearer when set against the prior evidence base. Earlier randomized trials had tested psychosocial pain interventions specifically tailored to patients in substance use disorder treatment, including work by Ilgen and colleagues and mindfulness-oriented recovery enhancement trials by Garland and colleagues, which showed that dedicated programs could help. But those studies evaluated interventions designed for the substance-using population, leaving open whether mainstream collaborative pain care, the kind most health systems could actually deploy, would work as well for these patients. A prior observational study by Morasco and colleagues had examined pain-related function over twelve months in primary care patients with musculoskeletal pain and found associations worth probing further. The new analysis closes that gap by embedding the substance use disorder question directly inside a rigorous randomized trial of standard collaborative care models, giving the finding a level of causal confidence that observational data cannot provide.

The opioid dose reduction component of the study carries particular weight given the national conversation about tapering. Systematic reviews, including one by Frank and colleagues, have documented that dose reduction and discontinuation of long-term opioid therapy can produce mixed patient outcomes, and observational studies from multiple health systems have linked rapid or forced tapering to overdose, mental health crisis, and other adverse events. The VOICE trial’s collaborative care approach, by contrast, paired dose reduction with active pain treatment, and the new analysis shows that patients with potential substance use disorder achieved dose reductions without differential harm to their pain outcomes. This suggests that the safest tapering is not simply a matter of lowering doses but of lowering them within a supportive treatment structure, and that patients with substance use disorder should not be steered away from such structures on the assumption that they will fail.

Several design features strengthen the study’s real-world relevance. The pragmatic trial design meant that interventions were delivered in ordinary VA primary care settings rather than in specialized research clinics, and the enrollment of 778 patients across multiple sites provided the statistical power to detect meaningful differences if they existed. The identification of potential substance use disorder relied on validated screening approaches, including instruments such as the AUDIT-C for alcohol and the TAPS tool for unhealthy substance use, supplemented by diagnostic codes whose validity in administrative data has been verified through chart review in prior work. The trial was registered at ClinicalTrials.gov as NCT03026790, funded by the Patient-Centered Outcomes Research Institute, and supported by the Department of Veterans Affairs, with the funder having no role in the design, analysis, or decision to publish.

The study’s limitations deserve honest acknowledgment. The population consisted of veterans, most of whom receive integrated care within a single health system, so generalization to civilian populations with fragmented insurance and care remains an empirical question. The substance use disorder classification was based on screening and potential criteria rather than structured clinical interviews, and the analysis examined outcomes at twelve months rather than over longer horizons. The parent trial compared two collaborative care variants and collapsed them for this analysis, so the results speak to collaborative care as a class rather than distinguishing which model works better for which subgroup. Nonetheless, the consistency of the findings across pain interference, pain intensity, and opioid dose outcomes lends credibility to the central conclusion.

The clinical implications are straightforward and potentially practice-changing. Roughly a third of patients on long-term opioid therapy carry a substance use disorder diagnosis, and clinicians have long faced a dilemma: treat the pain aggressively and risk worsening the addiction, or prioritize addiction treatment and leave the pain undertreated. These results suggest that the dilemma is partly false. Collaborative care interventions for chronic pain improved pain outcomes and reduced opioid doses in patients with and without potential substance use disorder alike, indicating that substance use disorder status should not gate access to structured pain treatment. As health systems continue to grapple with the twin burdens of chronic pain and the opioid crisis, the message from this trial is that integrated, team-based care can serve both populations, and that excluding patients with substance use disorder from such care is neither necessary nor supported by the evidence.

Subject of Research: Collaborative care treatment outcomes for chronic pain and opioid dose reduction in patients with and without substance use disorder

Article Title: Pain and Opioid Dose Reduction Based on Substance Use Disorder Status: Secondary Analysis from a Pragmatic Effectiveness Trial

Article References: Morasco, B. J., Hammett, P. J., Krebs, E. E., Seal, K. H., DeRonne, B. M., Lovejoy, T. I., Bohnert, A. S. B., Frank, J. W., Makris, U. E., Naylor, J. C., Painter, J. T., Borsari, B., Hagedorn, H. J., & Becker, W. C. (2026). Pain and Opioid Dose Reduction Based on Substance Use Disorder Status: Secondary Analysis from a Pragmatic Effectiveness Trial. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10816-6

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10816-6

Keywords: substance use disorder, chronic pain, long-term opioid therapy, opioid dose reduction, collaborative care, pragmatic trial, veterans health, pain interference, pain intensity, primary care, comparative effectiveness, opioid prescribing

The study is deeply rooted in the experiences and insights of 28 expert clinicians, who provided their perspectives on the multifaceted harms and benefits associated with long-term opioid medication. Chronic pain, defined as persistent pain lasting three months or longer, has seen a rise in prevalence, particularly in the context of non-cancer diagnoses. The implications of this epidemic are profound, necessitating a nuanced approach to pain management that weighs the potential benefits of opioids against the very real risks of addiction, overdose, and exacerbation of pain conditions.

One of the standout findings from this study is the notable lack of consensus among medical professionals regarding the optimal management strategy for chronic non-cancer pain. More specifically, the analysis reveals that only 36% of the experts advocate for the continuation of opioid therapy, while an equal proportion urges for its cessation. This division speaks to the broader tension within the medical community, where the stakes can involve not only a patient’s quality of life but also their long-term health outcomes.

The study’s authors emphasize the dangerous potential associated with rapid tapering of opioids, including withdrawal symptoms and a potential resurgence of chronic pain, or even the onset of mental health crises. Indeed, more than half of the surveyed experts voiced concerns regarding the dangers of abruptly stopping opioid therapy. This sentiment is integral in shaping protocols for pain management, indicating a cautious and calculated approach may be more beneficial than immediate cessation.

In pursuit of alternatives, some clinicians are advocating for transitioning patients to buprenorphine. This medication is notable for its dual action: it alleviates pain while simultaneously reducing the reinforcing effects associated with opioid dependence. By doing this, clinicians hope to mitigate withdrawal symptoms and cravings, ultimately facilitating a safer and more effective treatment regimen for those grappling with chronic pain.

The study also explored the potential benefits of integrating non-opioid therapies into the treatment spectrum, despite some experts being skeptical about their efficacy based on past experiences with these therapies. Emphasis was placed on the importance of shared decision-making between patients and providers, empowering patients to take an active role in their treatment. However, the lack of consensus on the execution of such measures underlines the necessity of establishing clearer guidelines rooted in evidence-based practices.

While most experts acknowledged the adverse effects of co-occurring conditions such as alcohol use and mental health disorders on patient safety, there was considerable variability in opinions regarding the assessment of opioid use disorder and overdose risk. This oversight may reflect a broader systemic issue in pain management, where many providers may prioritize pain relief over comprehensive assessments of potential addiction and risks.

The moral complexities of opioid prescription practices further complicate the issue of managing chronic pain. Kurt Kroenke, M.D., a co-author of the study, highlights that while the beneficial role of opioids in patient pain relief is well-established, the potential for abuse and adverse outcomes necessitates a careful evaluation of each patient’s specific circumstances. Moreover, taking a patient off opioids could lead to significant consequences, including not just the worsening of chronic pain but also the potential for drug-seeking behavior and increased risk of overdose.

Additionally, it’s important to consider the psychological aspects tied to chronic pain management. Patients may develop a dependency on opioids not just for pain relief but as a coping mechanism for underlying mental health issues. Therefore, when contemplating discontinuation of opioids, a multifaceted treatment approach that addresses both physical and psychological factors may be imperative to uphold patient well-being.

While opioid therapy remains a highly debated subject, Kroenke asserts that patients who still grapple with chronic pain despite being on prescribed opioids should be considered candidates for tapering and alternative therapies. This perspective emphasizes not only patient safety but also encourages movement towards treatment strategies that are less reliant on opioids, thereby reducing the potential for long-term dependence.

As the study draws to a close, it highlights the significant implications of professional liability fears, regulatory changes, and health system initiatives that make it challenging to establish clear guidelines on tapering or continuing opioid prescriptions. In this transitional period, the importance of ethical medical care remains critical, advocating for informed consent and dialogue based on mutual respect between healthcare providers and their patients.

In conclusion, the study underscores a critical gap in clinical practice guidelines regarding the management of patients who face risks from both continuing and discontinuing their long-term opioid therapy. Given the continuing evolution of pain management, there is an urgent need for ongoing discourse and research to ensure that clinicians and patients can navigate the complex terrain of chronic pain treatment effectively.

Subject of Research: Management of long-term opioid therapy in chronic pain patients
Article Title: Management of patients at risk of harms from both continuing and discontinuing their long-term opioid therapy: A qualitative study to inform the gap in clinical practice guidelines
News Publication Date: 25-Jan-2025
Web References: PubMed Study
References: Pain Practice
Image Credits: Not applicable

Keywords: Chronic Pain, Opioids, Pain Management, Buprenorphine, Tapering, Patient Safety, Addiction, Mental Health, Non-opioid Therapies, Shared Decision-Making, Healthcare Guidelines.