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Comment & Response |

What Ecologic Analyses Cannot Tell Us About Medical Marijuana Legalization and Opioid Pain Medication Mortality—Reply

Marcus A. Bachhuber, MD1,2,3; Brendan Saloner, PhD4,5; Colleen L. Barry, PhD, MPP3,4,5
[+] Author Affiliations
1Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania
2Robert Wood Johnson Foundation Clinical Scholars Program, University of Pennsylvania, Philadelphia
3Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
4Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
5Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
JAMA Intern Med. 2015;175(4):656-657. doi:10.1001/jamainternmed.2014.8027.
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In Reply We agree with Finney et al that large, prospective studies of the effects of medical cannabis in individuals with chronic pain are warranted. However, we believe that results from studies of state-level data can also be informative.

Robinson1 identified a fundamental concept, that associations between variables at the individual level may be different than associations between variables at the group level. However, group-level studies can be of great value when the unit of inference is the group (in the case of our report, the state) and individual-level data are unavailable.2 Furthermore, we are not simply comparing states with and without the policy at a single point of time, an inferential method often leading to flawed ecological correlations as Robinson1 illustrated. Rather, we are comparing changes before and after a state-level policy change relative to states where there was no policy change. This over-time variation allows us to statistically adjust for many of the idiosyncratic state-level differences that might otherwise lead to biased conclusions.3

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April 1, 2015
John W. Finney, PhD; Keith Humphreys, PhD; Alex H. S. Harris, PhD
1Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California2Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California
1Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California3Department of Orthopedic Surgery, Stanford University School of Medicine, Stanford, California
JAMA Intern Med. 2015;175(4):655-656. doi:10.1001/jamainternmed.2014.8006.
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