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

BMJ. 2021 Jan 27;372:m4957. doi: 10.1136/bmj.m4957.


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.

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Analgesics, Opioid / poisoning*
  • Commerce / legislation & jurisprudence
  • Commerce / statistics & numerical data*
  • Drug Overdose / mortality*
  • Drug Overdose / prevention & control
  • Female
  • Humans
  • Male
  • Marijuana Use / legislation & jurisprudence*
  • Medical Marijuana*
  • Middle Aged
  • Opioid-Related Disorders / mortality*
  • Opioid-Related Disorders / prevention & control
  • Regression Analysis
  • United States / epidemiology


  • Analgesics, Opioid
  • Medical Marijuana