Substance use disorder (SUD) is the persistent use of drugs despite negative outcomes, such as loss of income due to habitual intake, lost economic output, and severe social impacts (e.g., missed social events, isolation from family and friends).

There are various subtypes of SUD, including opioid use disorder (OUD), alcohol use disorder (AUD), and benzodiazepine use disorder (BUD). SUD is closely tied to addiction, but substance abuse does not always lead to addiction. Overuse of a prescription painkiller or binge drinking, for example, are signs of substance abuse, but physical and/or psychological dependence has not necessarily occurred yet.

substance abuse cost

The costs associated with substance abuse are enormous.

Even conservative estimates suggest substance abuse costs over $600 billion annually. Other estimates put the costs much higher: over $1 trillion for opioid use disorder alone and $3.73 trillion if intangible costs are also counted. Such huge numbers include not only opioids but also licit and illicit substances such as alcohol (almost $250 billion), tobacco (over $600 billion), and prescription sedatives like benzodiazepines.

Whichever number one decides to go with, there is a clear need to reduce the costs associated with substance abuse disorder.

With an increasing number of states in the U.S. legalizing medical cannabis to some extent, and many patients reporting a decrease in their use of narcotics/opioids, anxiolytics/benzodiazepines, and antidepressants, a question arises: could medical cannabis help reduce the costs associated with substance abuse and addiction?

More research into this area, including the endocannabinoid system (ECS)‘s role in drug reinforcement and reduction behaviors, could also help us learn more about other addiction and addiction-like disorders, such as gambling and eating disorders like anorexia and obesity.

Again, the costs associated with such conditions are huge. Some consider obesity the biggest health problem in the U.S., with other metabolic disorders like hypertension and diabetes also increasing in incidence. So, learning about the biology behind substance abuse can help us learn about other pressing health problems.

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Medical Cannabis Replacing Other Drugs? The Theory Behind Why (and Why Not)

The idea of using cannabis instead of other drugs is controversial, especially after years of cannabis’ reputation as a “gateway drug.”

The other common question is: “aren’t you just replacing one addiction for another?” The response to both of these ideas is that “cannabis could be seen as an exit drug” and that “cannabis is a safer crutch than many other drug replacements given during addiction treatment, especially as cannabis alone is unlikely to cause a deadly overdose.”

Before we come to any firm conclusion, we ought to look at the merits of both arguments. The picture is far more complicated than either argument gives credit for, and it could be said that both are true simultaneously. Medical cannabis can be helpful and ineffective, depending on the individual, the substance being replaced, and other comorbidities and socioeconomic factors. Here are some pros and cons for each.

Medical Cannabis for SUD and Addiction: the Pros

Targeting the ECS utilizing phytocannabinoids (plant cannabinoids) could help with several health problems that cause or are caused by endocannabinoid dysregulation or deficiency, i.e., the stress, inflammation, and immune system dysfunction associated when there is a problem with the production of the body’s natural cannabinoids, in particular anandamide and 2-AG. Addiction involves inflammation, as do common comorbidities like anxiety, ADHD and depression.

Tempering this inflammation using cannabinoids, which have many anti-inflammatory properties, could help reduce the need for more harmful substances, especially when managing chronic pain, neuropathic (nerve) pain, anxiety, autoimmune diseases, and neuroinflammatory diseases like multiple sclerosis (MS) or epilepsy.

Drugs commonly prescribed for such conditions include opioids, benzodiazepines (sedatives), steroids, stimulants, gabapentin, and antidepressants, many of which have adverse side effects much worse than cannabis (e.g., addiction, overdose, brain fog, appetite problems, nausea/vomiting, GI upset).

There are several other key reasons medical cannabis may help reduce the need for other drugs. These include:

  • The multi-receptor targeting properties of cannabis and its constituents, cannabinoids, terpenes and flavonoids. Medical cannabis contains many compounds that can “talk” to and influence the behavior of other receptor systems, including opioid receptors, serotonin receptors, and dopamine receptors. This can help reduce the need for additional drugs directly targeting these receptor sites, such as opioids and antidepressants.
  • The atypical cannabinoid/terpene, beta-caryophyllene, has anti-addictive properties that could help reduce the intake of alcohol, opioids, and stimulants. Beta-caryophyllene is often a prominent terpene found in cannabis and has analgesic and anti-inflammatory properties. CB2 receptors are thought to play a crucial role in addiction, and it seems that CB2 receptor agonists like beta-caryophyllene may help manage it.
  • The euphoric effects of THC can help stave off cravings.
  • The relaxing and anti-spasmodic effects of cannabis can help manage withdrawal symptoms like restless leg syndrome (RLS).
  • Other terpenes in cannabis, including myrcene, limonene, pinene, terpinolene (alpha-terpinene), linalool and humulene, have sedative and/or stimulating effects that can help manage anxiety, lift mood, reduce fatigue, aid sleep, reduce inflammation and improve focus. Moreover, terpenes have many anti-microbial properties.
  • Targeting serotonin receptors using receptor agonists like CBD could help reduce drug cravings. Serotonin receptor dysregulation has been implicated in lower mood and drug addiction. This is part of why other serotonin receptor agonists like psilocybin/psilocin and even LSD may be so useful and aid in overcoming addiction.

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Medical Cannabis for SUD and Addiction: the Cons

The fact is, that cannabis use disorder (CUD) is an issue. Despite not being deadly on its own, cannabis use can become problematic and result in psychological addiction that can impair function. CUD is thought to affect approximately 9% of cannabis users, or even as high as 10%-20% of daily users or those who started using cannabis in their teenage years. Other potential cons include:

  • The synergistic effects are caused by the combination of cannabis with other substances. For example, combining cannabis with high doses of opioids, sedatives, or alcohol may increase the chances of overdose.
  • Some research suggests that marijuana use during teenage years could help “prime” the brain for drug addiction, particularly cocaine. This lends some credence to the gateway theory of drug addiction (i.e., you start on “softer” drugs and then move on to harder ones), even if it hasn’t definitively been proven to exist.
  • Medical cannabis is not available in all states, and even in states where it’s legal, you may be ejected from a drug treatment program if you test positive for THC or any of its metabolites.
  • Medical cannabis alone does not necessarily help with the social factors of addiction. Patients must be willing to change peer groups if necessary. Lifestyle changes often need to be made. Extensive follow-ups and other treatment methods are often required to prevent relapse. This includes integration therapy, possibly group therapy, and different types of treatment.
  • The initial cost of accessing medical cannabis can be high compared to a prescription pill.
  • Smoking cannabis, in particular, can pose other potential health risks, such as respiratory disorders and, rarely, cannabinoid hyperemesis syndrome (CHS).
  • Cannabinoids like CBD can desensitize the liver enzyme cytochrome P450 (CYP 450), meaning some drugs are not metabolized if ingested alongside CBD, causing a potentially dangerous increase in the number of other drugs in the blood.
  • No definitive evidence that cannabis can help reduce the costs associated with other drugs.

What Does the Research Show?

  • Total Studies = 152 (including opioid use disorder, benzodiazepine use disorder, alcoholic liver disease, cocaine dependence, stimulant dependence, and adverse effects from MDMA/ecstasy)
  • Positive Studies = 140
  • Inconclusive Studies = 19
  • Negative Studies = 3
  • 80 Meta-Analyses (62 positive, 15 inconclusive, three negative); 43 Animal Studies (40 positive, three inconclusive); 7 Double-Blind Human Trials (6 positive, one inconclusive); 10 Human Trials (all positive)
  • 28 studies include CBD (25 positive, 3 inconclusive); 34 studies include THC (31 positive, 3 inconclusive); 1 study includes CBN (positive); 1 study includes THCV (positive)
  • No. of Leafwell Patients (2021) = 461 (opioid use disorder, or OUD)
  • In one Leafwell survey, some people used cannabis to reduce/replace alcohol intake (73 respondents, 19.5%) during the COVID-19 pandemic.
  • One survey of medical cannabis patients in California found that, out of 2,841 patients, “more than half (65.8%) indicated that CaM [cannabis as medicine] was a ‘much more effective’ treatment of their condition(s) compared to prescription drugs.” Tramadol was the most common prescription drug substituted, and other pain medications, antidepressants, and arthritis medications were also replaced.

The research shows a greater number of positive results for some drug classes than for others. Medical cannabis could benefit drugs with sedative effects like opiates/opioids, alcohol, benzodiazepines, and barbiturates. Still, results are more mixed regarding drugs with stimulating effects like cocaine or amphetamines.

There may also be differences between those who are abusing or addicted to prescription drugs and those who are addicted to illicit, non-prescription drugs, where the psychology behind the use may be slightly different (i.e., one is using it for a specific medical purpose compared to someone using a drug purely for recreation, although these populations may overlap).

substance abuse costs

Assessing the Costs of Cannabis vs. Other Drugs

According to one study:

Estimated annual per person hospital costs were $1,122 for the 17.6 million people with alcohol use disorders, $1,057 for the 4.2 million people with marijuana use disorders, and $2,783 for the 3.5 million people with substance use disorders involving other illicit drugs (Exhibit 2).

That is an estimated $4.4 billion yearly cost for hospitalizations due to cannabis/marijuana use disorder. The intangible health costs of CUD are more difficult to measure. Arguably, impacts like lost days at work or education, loss of connection with friends and family, and other quality of life measures are less severe with cannabis than other drugs. It is also arguable that, as cannabis can help improve function, reduce chronic pain, and does not cause death by overdose when used alone, the benefits outweigh the costs.

A good question someone might ask is this: if cannabis is improving one’s quality of life and helping reduce pain without the need for more addictive substances, is that not a high cost and healthcare burden saved on another budget sheet with a higher total itemized bill (i.e., alcohol, tobacco and/or opioid addiction)?

Moreover, some of the costs of hospitalization due to cannabis could be due to the black market conditions it is often sold in, where things like product safety, pollutants, and pesticides are not usually considered. Legalization could help reduce some of these costs further.

However, it is worth mentioning that other healthcare costs may be associated with cannabis use, especially if one is smoking cannabis. Like tobacco smoke, cannabis smoke irritates the lungs and throat. Although not considered as carcinogenic (cancer-causing) as tobacco, there still may be some health problems associated with cannabis use that need to be considered.

This includes an increased chance of psychosis in those susceptible to schizophrenia or bipolar disorder (although CBD may be useful for such conditions), stroke, or heart attack (although, again, there may be some uses here as well), or throat and lung diseases. Other costs, like traffic or workplace accidents, must be examined.

It would not be amiss to assume that the costs associated with some of these health problems may increase slightly if cannabis use becomes legalized and more widespread. One study also shows that smoking cannabis can reduce the short-term motivation to work for money, although the study’s testing method for workplace motivation (i.e., repeatedly pressing a key for a small amount of money) is questionable.

However, it is not wise to assume this will be the case. In the Netherlands, where cannabis is available to purchase quite easily (if not entirely legally), sales of medical cannabis decreased in 2020. Other studies suggest that cannabis is not a significant health problem in the Netherlands.

As for the motivation to earn money, it should be worth noting that many highly successful people productively utilize cannabis. Many factors could affect a cannabis user’s motivation to work, and it is not necessarily just the cannabis itself. Low pay, a lack of satisfaction in one’s job, and how peers treat one in the workplace are just a few of the factors that contribute to a lack of motivation.

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The Cost of Alcohol Use Disorder (AUD)

The estimated cost of alcohol use disorder is $249 billion per year, which includes a healthcare cost of $28 billion, a workplace productivity cost of $179, vehicle collisions cost of $13 billion, and criminal justice cost of $25 billion. An estimated 95,000 people (approximately 68,000 men and 27,000 women) die from alcohol-related causes annually.

Impact of Medical/Adult-Use Cannabis Legalization

Some states with legalized recreational cannabis have shown a decrease in alcohol sales.

The Cost of Opioid Use Disorder (OUD)

The estimated cost of the opioid epidemic in 2017 was around $1.021 trillion, with the cost of OUD being approximately $471 billion, the cost of a fatal opioid overdose being roughly $550 billion, and the rest on other costs such as road accidents and lost workplace productivity. Over 75,000 people in the U.S. lost their lives due to opioid overdose between April 2020 and April 2021.

When it comes to illicit substances, opioid overdose deaths are the most common, as 100,306 people lost their lives due to a drug overdose. This means that approximately three out of every four overdose deaths are due to opioids, with fentanyl being the main culprit. Illicit opioid overdoses constitute around 60,000 deaths, whereas prescription opioid overdose deaths constitute about 15,000.

Impact of Medical/Adult-Use Cannabis Legalization

There is significant evidence that medical cannabis can help reduce the need for opioid-based painkillers, which can positively impact the number of people who die from an overdose of illicit and prescription painkillers. There is an association between a higher number of cannabis dispensaries and lower opioid-mortality rates in the U.S.

The Cost of Benzodiazepine Use Disorder (BUD)

In 2019, an estimated 739,000 people (0.3% of the U.S. population) met the tranquilizer use disorder criteria, including sedative drugs like benzodiazepines.

Now, while BUD does not lead to as many overdose deaths as opioids (about 7,000 people compared to over 75,000 people), a significantly higher number of people are managing benzodiazepine or tranquilizer use disorder. It is not unusual to find people using benzodiazepines like diazepam (Valium) or alprazolam (Xanax) to help “come down” from stimulant drugs like cocaine, amphetamines, or ecstasy/MDMA.

BUD is also becoming a more common health problem — illicit benzodiazepine deaths increased 520% (from 51 to 317) from Q2 2019 to Q2 2020, and prescription benzodiazepine deaths increased 22% (from 921 to 1,122) from Q2 2019 to Q2 2020.

Long-term use of benzodiazepines has many negative outcomes and causes significant costs to healthcare and broader society. Benzodiazepines can also be quite an expensive class of drug to prescribe, especially when it comes to proprietary name brands.

Impact of Medical/Adult-Use Cannabis Legalization

Cannabinoids like CBD can help reduce reliance on benzodiazepine-based anti-seizure medications.

One CBD-based medication, Epidiolex, is available on prescription. Many people have reported that medical cannabis helps reduce their anxiolytic (anti-anxiety) and sleep medications, which are benzodiazepine-based. This is because cannabis contains several sedative cannabinoids and terpenes (THC, high doses of CBD, CBN, myrcene, and humulene) that can help reduce the need for sedative medications.

The Cost of Tobacco Use Disorder

Smoking-related health problems cost the U.S. more than $300 billion per year.

This includes nearly $170 billion in direct medical care for adults and over $156 billion in lost productivity due to premature death and exposure to secondhand smoke. Cigarette smoking and tobacco use are thought to cause more than 480,000 deaths annually, including deaths from secondhand smoke. Life expectancy for smokers is about 10 years lower than for non-smokers.

Impact of Medical/Adult-Use Cannabis Legalization

There is some evidence that CBD could be used to reduce a person’s pleasure from smoking cigarettes, but it is not known whether cannabis can impact tobacco sales.

Sadly, some evidence shows that cigarette sales rise in states with legalized adult-use cannabis, but this is not always the case. Careful dosing of medical cannabis and tinctures (e.g., CBD oils) may help reduce the desire for tobacco products.

The Cost of Stimulant and Cocaine Abuse

Amphetamine-type stimulants are the second-most illicit substance globally, after cannabis.

Although not as potent as opioids in terms of harm associated with use, stimulant addiction can cause a severe drop in the quality of life of individuals and prove to be highly destructive to society at large. Specific stimulant abuse-based costs are not easy to find, but they can be considered relatively high due to their abuse potential.

Regarding illicit substances, methamphetamine and cocaine abuse come second and third respectively to opioids in drug overdose deaths — over 20,000 people and over 19,000 people died from amphetamine (primarily methamphetamine) and cocaine overdose in 2020.

Impact of Medical/Adult-Use Cannabis Legalization

There is evidence that medical cannabis can help reduce the need for stimulant-based ADHD medications, with the terpene limonene showing particular promise in reducing methamphetamine intake.

Some other studies have shown similar results with different cannabinoids, where CBD can reduce cravings for stimulant drug intake. There is little data available on the effects of cannabis legalization on amphetamine or cocaine use.

substance abuse costs

Could Medical Cannabis Help Reduce Healthcare Costs Associated with Addiction?

According to the data, the answer is a tentative “Yes.” Several studies have shown reduced opioid, alcohol, antidepressant, and sedative intake when medical cannabis is legalized.

There is some sound science backing the concept of cannabis as an exit drug. Many patients also prefer the effects medical cannabis has compared to prescription medications, many of which can have several harmful side effects.

However, the answer is a “tentative yes” as we do not know precisely how much money cannabis use disorder will cost society, especially in the long term.

On the whole, when considering the harms and adverse effects of cannabis compared to other drugs, it could be said that legalizing cannabis at least medically would increase the quality of life and reduce opioid and alcohol intake for a significant number of people.