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Association between county level cannabis dispensary counts and opioid related mortality rates in the United States: panel data study

BMJ 2021; 372 doi: (Published 27 January 2021) Cite this as: BMJ 2021;372:m4957

Linked Editorial

Cannabis liberalisation and the US opioid crisis

  1. Greta Hsu, professor1,
  2. Balázs Kovács, associate professor2
  1. 1Graduate School of Management, University of California, Davis, California, USA
  2. 2School of Management, Yale University, 165 Whitney Avenue, New Haven, CT 06520, USA
  1. Correspondence to: B Kovács balazs.kovacs{at}
  • Accepted 25 November 2020


Objective To examine county level associations between the prevalence of medical and recreational cannabis stores (referred to as dispensaries) and opioid related mortality rates.

Design Panel regression methods.

Setting 812 counties in the United States in the 23 states that allowed legal forms of cannabis dispensaries to operate by the end of 2017.

Participants The study used US mortality data from the Centers for Disease Control and Prevention combined with US census data and data from on storefront dispensary operations. Data were analyzed at the county level by using panel regression methods.

Main outcome measure The main outcome measures were the log transformed, age adjusted mortality rates associated with all opioid types combined, and with subcategories of prescription opioids, heroin, and synthetic opioids other than methadone. The associations of medical dispensary and recreational dispensary counts with age adjusted mortality rates were also analyzed.

Results County level dispensary count (natural logarithm) is negatively related to the log transformed, age adjusted mortality rate associated with all opioid types (β=−0.17, 95% confidence interval −0.23 to −0.11). According to this estimate, an increase from one to two storefront dispensaries in a county is associated with an estimated 17% reduction in all opioid related mortality rates. Dispensary count has a particularly strong negative association with deaths caused by synthetic opioids other than methadone (β=−0.21, 95% confidence interval −0.27 to −0.14), with an estimated 21% reduction in mortality rates associated with an increase from one to two dispensaries. Similar associations were found for medical versus recreational storefront dispensary counts on synthetic (non-methadone) opioid related mortality rates.

Conclusions Higher medical and recreational storefront dispensary counts are associated with reduced opioid related death rates, particularly deaths associated with synthetic opioids such as fentanyl. While the associations documented cannot be assumed to be causal, they suggest a potential association between increased prevalence of medical and recreational cannabis dispensaries and reduced opioid related mortality rates. This study highlights the importance of considering the complex supply side of related drug markets and how this shapes opioid use and misuse.


  • Contributors: GH and BK together collected and analyzed the data. GH wrote the first draft and BK commented on it. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. Balazs Kovacs is the guarantor.

  • Funding: No relevant funding.

  • Competing interests statement: All authors have completed the ICMJE uniform disclosure form at and declare: no support from any organization for the submitted work; no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: Ethical approval was not required.

  • Data sharing: Given our data agreement with the Centers for Disease Control and Prevention, the raw data will not be shared.

  • The lead author (the manuscript’s guarantor) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

  • Dissemination to participants and related patient and public communities: The results of this study will be distributed to community members through press releases and blogs, including the use of lay summaries describing the research and its results.

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

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