Medical Marijuana and Marijuana Legalization

Medical marijuana laws (MMLs) and dispensary provisions not associated with higher odds of adolescent marijuana or heavy marijuana use: A 46 State Analysis, 1991-2015

Background: States are rapidly moving to reverse marijuana prohibition, most frequently through legalization of medical marijuana laws (MMLs), and there is concern that marijuana legalization may affect adolescent marijuana use. Methods: This natural-experimental study used state Youth Risk Behavior Survey (YRBS) data collected from participants in grades 9-12 from 1991 to 2015 in 46 states (N = 1,091,723). Taking advantage of heterogeneity across states in MML status and MML dispensary design, difference-in-difference estimates compared states with enacted MMLs/dispensaries to non-MML/dispensaries states. Multivariable logistic regression modeling was used to adjust for state and year effects, and student demographics. The main outcome assessed was past 30-day adolescent marijuana use ["any" and "heavy" (≥20)]. Results: In the overall sample, the adjusted odds of adolescents reporting any past 30-day marijuana use was lower in states that enacted MMLs at any time during the study period (OR 0.94, 95% CI 0.89 to 0.99; p < .05), and in states with operational dispensaries in 2015 (OR 0.93, 95% CI 0.88 to 0.99; p < .05). Among grade cohorts, only 9th graders showed a significant effect, with lower odds of use with MML enactment. We found no effects on heavy marijuana use. Conclusions: This study found no evidence between 1991 and 2015 of increases in adolescents reporting past 30-day marijuana use or heavy marijuana use associated with state MML enactment or operational MML dispensaries. In a constantly evolving marijuana policy landscape, continued monitoring of adolescent marijuana use is important for assessing policy effects.

Random urine drug testing among patients receiving opioid therapy for cancer pain

BACKGROUND

There is limited information regarding the true frequency of nonmedical opioid use (NMOU) among patients receiving opioid therapy for cancer pain. Data to guide patient selection for urine drug testing (UDT) as well as the timing and frequency of ordering UDT are insufficient. This study examined the frequency of abnormal UDT among patients with cancer who underwent random UDT and their characteristics.

METHODS

Demographic and clinical information for patients with cancer who underwent random UDT were retrospectively reviewed and compared with a historical cohort that underwent targeted UDT. Random UDT was ordered regardless of a patient's risk potential for NMOU. Targeted UDT was ordered on the basis of a physician's estimation of a patient's risk for NMOU.

RESULTS

In all, 552 of 573 eligible patients (96%) underwent random UDT. Among these patients, 130 (24%) had 1 or more abnormal results; 38 of the 88 patients (43%) who underwent targeted UDT had 1 or more abnormal results. When marijuana was excluded, 15% of the random group and 37% of the targeted group had abnormal UDT findings (P < .001). It took a shorter time from the initial consultation to detect 1 or more abnormalities with the random test than the targeted test (median, 130 vs 274 days; P = .02). Abnormal random UDT was independently associated with younger age (P < .0001), male sex (P = .03), Cut Down, Annoyed, Guilty, and Eye Opener-Adapted to Include Drugs positivity (P = .001), and higher Edmonton Symptom Assessment System anxiety (P = .01).

CONCLUSIONS

Approximately 1 in 4 patients receiving opioids for cancer pain at a supportive care clinic who underwent random UDT had 1 or more abnormalities. Random UDT detected abnormalities earlier than the targeted test. These findings suggest that random UDT is justified among patients with cancer pain.

State Medical Cannabis Laws Associated With Reduction in Opioid Prescriptions by Orthopaedic Surgeons in Medicare Part D Cohort

INTRODUCTION

Opioid prescriptions and abuse remain a significant national concern. Cannabinoids offer a potentially attractive nonopioid analgesic option for orthopaedic patients, and 32 US states have passed medical cannabis laws (MCLs), legalizing patient access to cannabinoids. We examine the association between implementation of state cannabis laws and prescribing patterns for opioids by orthopaedic surgeons in Medicare Part D patients between 2013 and 2017.

METHODS

Using the Medicare Part D Prescription Drug Event database, we measured annual aggregate daily doses of all opioid medications (excluding buprenorphine) prescribed by orthopaedic surgeons in each US state (and DC), in addition to total daily doses of opioid medications by generic name (hydrocodone, oxycodone, fentanyl, morphine, methadone, and "other opioids"). We used adjusted linear regression models to examine associations between state-specific cannabis regulations (state MCL, MCL type-dispensary or home cultivation, and recreational cannabis legalization) and annual total daily doses of opioid medications (all opioids and opioid types, separately).

RESULTS

State MCLs were associated with a statistically significant reduction in aggregate opioid prescribing of 144,000 daily doses (19.7% reduction) annually (95% confidence interval [CI], -0.535 to -0.024 million; P < 0.01). States with MCLs allowing access to in-state dispensaries had a statistically significant reduction in total opioid prescriptions of 96,000 daily doses (13.1%) annually (95% CI, -0.165 to -0.026 million; P < 0.01). Specifically, MCLs were associated with a statistically significant reduction of 72,000 daily doses of hydrocodone annually (95% CI, -0.164 to -0.019 million; P < 0.01). No significant association between recreational marijuana legalization and opioid prescribing was found.

CONCLUSION

Orthopaedic surgeons are among the highest prescribers of opioids, highlighting the importance of providing nonopioid analgesic alternatives in efforts to reduce opioid use in the patient cohort. This study is the first to examine the association between implementation of state cannabis laws and prescribing patterns for opioids by orthopaedic surgeons in Medicare Part D patients.

LEVEL OF EVIDENCE

Population-based ecological study.

Past 30-Day Marijuana Vaping: Prevalence and Predictors of Use in a Nationally Representative Study of U.S. Youth

INTRODUCTION

Vaping has become an increasingly common mode of administration for marijuana among youth, but there are limited data on its prevalence. There is a need to better understand youth prevalence of past 30-day marijuana vaping and its predictors.

METHODS

Data were from a nationally representative sample of students from the Monitoring the Future survey in 2018 (N=9,131). This study examined past 30-day prevalence of marijuana vaping, and for a subset with complete data (n=5,755), the predictors of marijuana vaping among respondents asked about that behavior. Bivariate chi-square tests and multivariable logistic regression estimated the extent to which various factors were associated with marijuana vaping. These factors included the current use of various substances, school-related risk behaviors, attitude and risk behaviors related to substance use, and selected sociodemographic variables.

RESULTS

Past 30-day prevalence of marijuana vaping was higher among 10th graders, male youth, and those in the Other race/ethnicity category. Students who engaged in current past 30-day alcohol use, cigarette use, binge drinking, and nonmedical use of prescription drugs had significantly greater odds of past 30-day marijuana vaping. Past 30-day use was more common among students with a lower perceived risk of marijuana use, those who claimed that it was easy to obtain a vaporizer or marijuana, students with a lower grade point average, and those with recent truancy.

CONCLUSIONS

Past 30-day marijuana vaping is prevalent among U.S. students, and there are robust associations between use and school- and substance-related risk behaviors. These results suggest that the emergence of vaping products might redefine populations at risk, which should be taken into account by marijuana regulatory policies or prevention programs.

Regulation of Calcium Oscillations in β-Cells by Co-activated Cannabinoid Receptors

Pharmacological treatment of pancreatic β cells targeting cannabinoid receptors 1 and 2 (CB1 and CB2) has been shown to result in significant effects on insulin release, possibly by modulating intracellular calcium levels ([Ca²⁺]_i). It is unclear how the interplay of CB1 and CB2 affects insulin secretion. Here, we demonstrate by the use of highly specific receptor antagonists and the recently developed photo-releasable endocannabinoid 2-arachidonoylglycerol that both receptors have counteracting effects on cytosolic calcium oscillations. We further show that both receptors are juxtaposed in a way that increases [Ca²⁺]_i oscillations in silent β cells but dampens them in active ones. This study highlights a functional role of CB1 and CB2 acting in concert as a compensator/attenuator switch for regulating β cell excitability.

Cannabis attitudes and patterns of use among followers of the Allergy & Asthma Network

BACKGROUND

Cannabis use in patients with allergy/asthma, a high-risk group for adverse effects to cannabis, is unknown.

OBJECTIVE

To determine the patterns of use and attitudes toward cannabis in patients with allergy/asthma.

METHODS

An anonymous online survey on cannabis attitudes and use was conducted through the Adult Allergy & Asthma Network. The Asthma Control Test assessed asthma burden. Cluster analyses determined group phenotypes and factor analyses condensed cannabis subjective effects into similar response patterns.

RESULTS

A total of 88 of 489 respondents (18.0%) currently use cannabis with most at the age of less than 50 years old, of female sex, and of White race. Of the noncannabis users (N = 401), 2.5% reported cannabis allergy. Cluster analysis revealed that a liberal attitude toward cannabis was associated with current cannabis use (P < .001). Among current cannabis users, 40.9% of their physicians inquired on cannabis use; only 37.5% of users wanted to discuss cannabis. In addition, 65.9% used cannabis for medical or medical/recreational purposes. Cannabinoids used were tetrahydrocannabinol (33.0%), cannabidiol (19.3%), or both (47.7%). Smoked and vaped cannabis were reported by 53.4% and 35.2%, respectively. Furthermore, 51 cannabis users (58.0%) reported current asthma with 39.2% uncontrolled; of these, 50% smoked cannabis. Compared with current participants with asthma not using cannabis, those currently using cannabis experienced similar levels of asthma control, quality of life, and frequency of asthma exacerbations. Positive effects were endorsed more than negative effects to cannabis (P < .001). Moreover, 19.3% of cannabis users reported coughing that was associated with smoking cannabis (P < .001).

CONCLUSION

Cannabis was used by less than 20% of the respondents with positive effects more frequent than negative effects. Half of cannabis users with uncontrolled asthma smoke cannabis, but only a minority of the physicians inquire about its use.

Mode of Marijuana Use among Young Adults: Perceptions, Use Profiles, and Future Use

BACKGROUND

Given changes in marijuana regulations, retail, and products and potential impact on use, we examined young-adult perceptions of different modes of use, the proportion using via different modes (e.g. smoking, vaping, ingesting), and associations with the use levels and stability of use over time.

METHODS

We analyzed baseline and one-year follow-up survey data (Fall 2018-2019) among 3,006 young adults (ages 18-34) across six metropolitan areas (Atlanta, Boston, Minneapolis-St. Paul, Oklahoma City, San Diego, Seattle). Measures included marijuana use frequency and mode, sociodemographics, other substance use, and social influences.

RESULTS

Participants' rated the following modes of use as: least harmful/addictive: topicals, oral pills, joint/bowl; most socially acceptable: joint/bowl, edibles/beverages, vaporized; and most harmful/addictive and least acceptable: wrapped, vaped, or waterpipe/bong with tobacco. Baseline past-month use prevalence was 39.2% (n = 1,178). Most frequent use mode was smoking (joints/bowls/cigar papers; 54.0%), vaping (21.8%), via pipe/bong (15.1%), and ingesting (9.1%). Multinomial logistic regression indicated that participants in states with legalized marijuana retail were at greater odds for using via modes other than smoking; participants more frequently using were at greater odds for using via pipe/bong (vs. smoking) (ps < .001). Regarding most frequent mode across time, most consistent was pipe/bong (53.3%), followed by smoking (49.3%), vaping (44.5%), and ingesting (32.9%). Past-month abstinence at follow-up was most common among those originally ingesting (34.3% abstinent), followed by smoking (23.6%), vaping (18.8%), and pipe/bong (14.8%).

CONCLUSIONS

Ongoing surveillance is needed to understand marijuana use patterns over time across different user groups (particularly by mode) and to inform interventions promoting abstinence.

Exposure to Δ9-tetrahydrocannabinol during rat pregnancy leads to impaired cardiac dysfunction in postnatal life

BACKGROUND

Cannabis use in pregnancy leads to fetal growth restriction (FGR), but the long-term effects on cardiac function in the offspring are unknown, despite the fact that fetal growth deficits are associated with an increased risk of developing postnatal cardiovascular disease. We hypothesize that maternal exposure to Δ9-tetrahydrocannabinol (Δ9-THC) during pregnancy will impair fetal development, leading to cardiac dysfunction in the offspring.

METHODS

Pregnant Wistar rats were randomly selected and administered 3 mg/kg of Δ9-THC or saline as a vehicle daily via intraperitoneal injection from gestational days 6 to 22, followed by echocardiogram analysis of cardiac function on offspring at postnatal days 1 and 21. Heart tissue was harvested from the offspring at 3 weeks for molecular analysis of cardiac remodelling.

RESULTS

Exposure to Δ9-THC during pregnancy led to FGR with a significant decrease in heart-to-body weight ratios at birth. By 3 weeks, pups exhibited catch-up growth associated with significantly greater left ventricle anterior wall thickness with a decrease in cardiac output. Moreover, these Δ9-THC-exposed offsprings exhibited increased expression of collagen I and III, decreased matrix metallopeptidase-2 expression, and increased inactivation of glycogen synthase kinase-3β, all associated with cardiac remodelling.

CONCLUSIONS

Collectively, these data suggest that Δ9-THC-exposed FGR offspring undergo postnatal catch-up growth concomitant with cardiac remodelling and impaired cardiac function early in life.

IMPACT

To date, the long-term effects of perinatal Δ9-THC (the main psychoactive component) exposure on the cardiac function in the offspring remain unknown. We demonstrated, for the first time, that exposure to Δ9-THC alone during rat pregnancy results in significantly smaller hearts relative to body weight. These Δ9-THC-exposed offsprings exhibited postnatal catch-up growth concomitant with cardiac remodelling and impaired cardiac function. Given the increased popularity of cannabis use in pregnancy along with rising Δ9-THC concentrations, this study, for the first time, identifies the risk of perinatal Δ9-THC exposure on early postnatal cardiovascular health.

Trends and correlates of Internet support group participation for mental health problems in the United States, 2004-2018

PURPOSE

This study sought to examine the trends in Internet support group (ISG) participation among U.S. adults and to investigate the sociodemographic and behavioral health profiles of ISG participants.

METHODS

Data was derived from the National Survey on Drug Use and Health (2004-2018, n = 625,883). Logistic regression was used to examine significance of trend year and correlates of ISG participation. Latent class analysis was conducted to identify subtypes of ISG participants.

RESULTS

The proportion of U.S. adults participating in ISG increased significantly from 2.29% (2004-2007) to 3.55% (2016-2018). ISG participants were less likely to be male, 35 or older, be part of an ethnic/racial minority group, or have household incomes between $20,000 and $49,999. Black/African American participants and those classified as "other" race showed the largest percent increases, while Hispanics showed no change. ISG participants were more likely to have experienced a depressive episode and to have used cannabis. Three subtypes of ISG participants were identified, including the Lower Behavioral Health Risk group (62%), the Elevated Behavioral Health Risk group (24%), and the Depression, Cigarettes, and Cannabis group (14%).

CONCLUSION

Overall, we found an increasing trend in seeking mental health care through ISG among US adults since the early 2000s. While disparities among some disadvantaged groups such as Blacks/African Americans and individuals with lower household income were diminishing, continuing efforts to engage men, older adults, and Hispanics in ISG are needed. This investigation also identified distinct subtypes of ISG participants and provides important implications for future research on ISG.

The Attitudes and Beliefs of Family Physicians Regarding the Use of Medical Cannabis, Knowledge of Side Effects, and Barriers to Use: A Comparison Between Residents and Specialists

BACKGROUND

Israel has a regulated system with clearly defined indications for treatment with medical cannabis.

STUDY QUESTION

The main question was whether family physicians in southern Israel face barriers/knowledge gaps in prescribing cannabis for medical indications. The secondary question was whether there was a difference between residents and specialists in family medicine.

STUDY DESIGN

A questionnaire-based cross-sectional study.

MEASURES AND OUTCOMES

Attitudes of the participating physicians on the use of medical cannabis; comparison of attitudes of specialists in family medicine and residents on the use of medical cannabis.

RESULTS

One hundred and fifty-two family physicians participated in the study including 48 residents. More than 78% supported the use of medical cannabis and about 63% supported it's legalization. About 84% of the physicians believed that medical cannabis helped cancer patients and 82% believed it helped in the chronic pain. Only 28.3% believed that family physicians should recommend the use of medical cannabis. The physicians were well aware of the psychiatric (82%) and the neurological (78%) adverse effects of medical cannabis. Most (68%) were not willing to prescribe medical cannabis. No socio-demographic characteristic was associated with willingness to prescribe cannabis. About 95% of the physicians believed that the main barrier to recommending treatment was its potential for abuse, 66% percent-the danger that it would leak to the general public. About 60% of the specialists were not prepared to undergoing training in the prescription of medical cannabis compared with 31% of the residents (P = 0.004).

CONCLUSIONS

Family physicians are concerned about recommending medical cannabis. It is encouraging that residents are motivated to undergo training to prescribe medical cannabis. There remain medical indications and adverse effects that family physicians are less aware of. Further studies should focus on effective ways to improve the level of physicians' knowledge on the issue.

Does cannabis alleviate tinnitus? A review of the current literature

OBJECTIVES

Endocannabinoid pathways have been proposed to affect the underlying pathophysiology of tinnitus. The aim of this study is to evaluate the scope and findings of existing literature on the relationship between cannabis and cannabinoid pathways and tinnitus.

METHODS

We conducted a review of animal, clinical and survey studies investigating the relationship between the use of cannabis-derived agents and tinnitus. Using pertinent keywords and MeSH terms on PubMed, relevant studies were identified, yielding four animal studies, two large cross-sectional survey studies, one clinical cross-over study, and one case report.

RESULTS

Animal studies revealed that cannabinoid receptor expression in the cochlear nucleus varied with tinnitus symptomatology and the use of cannabinoid agents either increased or had no effect on tinnitus-related behavior. Survey studies yielded conflicting results between cannabis use and tinnitus in the general population. Clinical data is largely lacking, although a small cohort study showed a dose-dependent relationship between tetrahydrocannabinol consumption and frequency of tinnitus episodes in patients receiving treatment for cancer.

CONCLUSION

While animal studies have revealed that cannabinoid receptors likely have a role in modulating auditory signaling, there is no compelling data either from animal or human studies for the use of cannabinoids to alleviate tinnitus. Further research is necessary to elucidate their precise role to guide development of therapeutic interventions.

LEVEL OF EVIDENCE

NA.

Medicinal and Recreational Marijuana: Review of the Literature and Recommendations for the Plastic Surgeon

Supplemental Digital Content is available in the text.

With the shift in public opinion and legalization of cannabis for therapeutic and recreational use, cannabis consumption has become more common. This trend will likely continue as decriminalization and legalization of marijuana and associated cannabinoids expand. Despite this increase in use, our familiarity with this drug and its associated effects remains incomplete. The aim of this review is to describe the physiologic effects of marijuana and its related compounds, review current literature related to therapeutic applications and consequences, discuss potential side effects of marijuana in surgical patients, and provide recommendations for the practicing plastic surgeon. Special attention is given to areas that directly impact plastic surgery patients, including postoperative pain, nausea and vomiting and wound healing. Although the literature demonstrates substantial support for marijuana in areas such as chronic pain and nausea and vomiting associated with chemotherapy, the data supporting its use for common perioperative problems are lacking. Its use for treating perioperative problems, such as pain and nausea, is poorly supported and requires further research.

State medical marijuana laws, cannabis use and cannabis use disorder among adults with elevated psychological distress

BACKGROUND

Cannabis use and cannabis use disorder are more prevalent in U.S. states with medical marijuana laws (MMLs), as well as among individuals with elevated psychological distress. We investigated whether adults with moderate and serious psychological distress experienced greater levels of cannabis use and/or disorder in states with MMLs compared to states without MMLs.

METHODS

National Survey of Drug Use and Health data (2013-2017) were used to compare past-month cannabis use, daily cannabis use, and cannabis use disorder prevalence among adults with moderate and serious psychological distress in states with versus without MMLs. We executed pooled multivariable logistic regression analyses to test main effects of distress, MMLs and their interaction, after adjustment.

RESULTS

Compared to states without MMLs, states with MMLs had higher adjusted prevalence of past-month use (11.1 % vs. 6.8 %), daily use (4.0 % vs. 2.2 %), and disorder (1.7 % vs. 1.2 %). Adults with moderate and serious psychological distress had greater adjusted odds of any use (AORs of 1.72 and 2.22, respectively) and of disorder (AORs of 2.17 and 2.94, respectively), compared to those with no/mild distress. We did not find evidence of an interaction between MMLs and distress category for any outcome.

CONCLUSIONS

Associations between elevated distress and cannabis use patterns are no greater in states with MML. However, cannabis use is more prevalent in MML states. Thus, higher base rates of cannabis use and disorder among adults with elevated distress are proportionally magnified in these states.

Medical cannabis use in the United States: a retrospective database study

Introduction

Growing interest in the medicinal properties of cannabis has led to an increase in its use to treat medical conditions, and the establishment of state-specific medical cannabis programs. Despite medical cannabis being legal in 33 states and the District of Colombia, there remains a paucity of data characterizing the patients accessing medical cannabis programs.

Methods

We retrospectively reviewed a registry with data from 33 medical cannabis evaluation clinics in the United States, owned and operated by CB2 Insights. Data were collected primarily by face-to-face interviews for patients seeking medical cannabis certification between November 18, 2018 and March 18, 2020. Patients were removed from the analysis if they did not have a valid date of birth, were less than 18, or did not have a primary medical condition reported; a total of 61,379 patients were included in the analysis. Data were summarized using descriptive statistics expressed as a mean (standard deviation (SD)) or median (interquartile range (IQR)) as appropriate for continuous variables, and number (percent) for categorical variables. Statistical tests performed across groups included t-tests, chi-squared tests and regression.

Results

The average age of patients was 45.5, 54.8% were male and the majority were Caucasian (87.5%). Female patients were significantly older than males (47.0 compared to 44.6). Most patients reported cannabis experience prior to seeking medical certification (66.9%). The top three mutually exclusive primary medical conditions reported were unspecified chronic pain (38.8%), anxiety (13.5%) and post-traumatic stress disorder (PTSD) (8.4%). The average number of comorbid conditions reported was 2.7, of which anxiety was the most common (28.3%). Females reported significantly more comorbid conditions than males (3.1 compared to 2.3).

Conclusion

This retrospective study highlighted the range and number of conditions for which patients in the US seek medical cannabis. Rigorous clinical trials investigating the use of medical cannabis to treat pain conditions, anxiety, insomnia, depression and PTSD would benefit a large number of patients, many of whom use medical cannabis to treat multiple conditions.

Current marijuana use among women of reproductive age

BACKGROUND

The objective of this study was to estimate the prevalence of current (past 30 days) marijuana use and its associations with demographic, other substance use, chronic disease, physical health and mental health measures among women of reproductive age (18-44 years) in 12 US states.

METHODS

This analysis used 2016 Behavioral Risk Factor Surveillance System (BRFSS) data from 16,556 women of reproductive age in 12 US states. Women self-reported current marijuana use and covariates. Weighted χ² statistics and adjusted prevalence ratios (aPR) were calculated accounting for the complex survey design.

RESULTS

Among women of reproductive age, 9.9 % reported current marijuana use. Current cigarette use (aPR: 2.0, 95 % CI: 1.6, 2.6), current e-cigarette use (aPR: 1.9, 95 % CI: 1.4, 2.6), binge drinking (aPR: 2.6, 95 % CI: 1.9, 3.6), ever having received a depression diagnosis (aPR: 1.6, 95 % CI: 1.2, 2.1), and ≥14 days of poor mental health in the past 30 days (aPR: 1.8, 95 % CI: 1.3, 2.4) were all associated with higher adjusted prevalence of current marijuana use. Reporting ≥14 days of poor physical health within the last 30 was associated with a 40 % lower adjusted prevalence of current marijuana use (aPR: 0.6, 95 % CI: 0.4, 0.8).

CONCLUSION

Current marijuana use among women of reproductive age was associated with other substance use, poor mental health, and depression. As state laws concerning marijuana use continue to change, it is important to monitor usage patterns and to assess associated health risks in this population.

Edmonton Symptom Assessment Scale and Clinical Characteristics Associated With Cannabinoid Use in Oncology Supportive Care Outpatients

BACKGROUND

Information about the frequency of cannabinoid use and the clinical characteristics of its users in oncology supportive care is limited. This study explored associations between cannabinoid use and cancer-related clinical characteristics in a cancer population.

PATIENTS AND METHODS

This retrospective review included 332 patients who had a urine drug test (UDT) for tetrahydrocannabinol (THC) together with completion of an Edmonton Symptom Assessment Scale (ESAS) and cannabinoid history questionnaire on the same day that urine was obtained during 1 year in the supportive care clinic.

RESULTS

The frequency of positive results for THC in a UDT was 22.9% (n=76). Significant statistical differences were seen between THC-positive and THC-negative patients for age (median of 52 [lower quartile, 44; upper quartile, 56] vs 58 [48; 67] years; P<.001), male sex (53.9% vs 39.5%; P=.034), and past or current cannabinoid use (65.8% vs 26.2%; P<.001). Statistical significance was observed in ESAS items between the THC-positive and THC-negative groups for pain (7 [lower quartile, 5; upper quartile; 8] vs 5 [3; 7]; P=.001), nausea (1 [0; 3] vs 0 [0; 3]; P=.049), appetite (4 [2; 7] vs 3 [0; 5.75]; P=.015), overall well-being (5.5 [4; 7] vs 5 [3; 6]; P=.002), spiritual well-being (5 [2; 6] vs 3 [1; 3]; P=.015), insomnia (7 [5; 9] vs 4 [2; 7]; P<.001), and total ESAS (52 [34; 66] vs 44 [29; 54]; P=.001). Among patients who reported current or past cannabinoid use, THC-positive patients had higher total scores and scores for pain, appetite, overall well-being, spiritual well-being, and insomnia than THC-negative patients.

CONCLUSIONS

Patients with cancer receiving outpatient supportive care who had positive UDT results for THC had higher symptom severity scores for pain, nausea, appetite, overall and spiritual well-being, and insomnia compared with their THC-negative counterparts. These results highlight potential opportunities to improve palliative care.

Regular cannabis use is associated with blunted affective, but not cardiovascular, stress responses

AIMS

To examine the potential impact of regular cannabis use on cardiovascular and subjective responses to acute stress.

DESIGN

We used a quasi-experimental design in which subjective states and cardiovascular measures were obtained during rest and in response to acute stress challenges in a sample of regular cannabis users and non-users.

PARTICIPANTS

Seventy-nine adults (forty-five cannabis users and thirty-four non-users).

MEASUREMENTS

We measured subjective states (positive affect, state stress, state anxiety, cannabis craving) and cardiovascular indicators (blood pressure, heart rate, mean arterial pressure) during baseline rest and in response to public speaking, mental arithmetic, and cold-pressor challenges. Regular cannabis use was established via self-report and was confirmed with a positive urine drug test.

FINDINGS

Regular cannabis use was associated with blunted positive affect (F = 5.67, p = .002), state stress (F = 6.05, p = .002), and state anxiety (F = 6.48, p < .001) in response to acute stress challenges. There was no evidence of an association between cannabis use and cardiovascular responses (Fs ≤ 1.54; Ps ≥ 0.21). Contrary to expectations, cannabis craving decreased in response to stress challenges (F = 8.44, p < .001).

CONCLUSION

Chronic cannabis use is associated with blunted positive and negative (stress, anxiety) affective responses to acute stress, indicating emotional dysregulation in this population.

Acute effects of cannabis consumption on exercise performance: a systematic and umbrella review

INTRODUCTION

The goal of this systematic and umbrella review was to regroup all systematic reviews, non-systematic reviews and all original articles into one convenient publication that would facilitate the theoretical and applied scientific investigations directed on cannabis consumption and exercise performance, to update current findings on the matters, and assess evidence quality.

EVIDENCE ACQUISITION

The systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) method. A computer-based systematic search was conducted in September 2019 through the Pubmed, Scopus and SPORTDiscus databases. The reliability of the systematic search was assured by having the article selection process entirely repeated by a second author. Strength of evidence of the selected articles was assesses using a modified version of the Downs and Black Checklist.

EVIDENCE SYNTHESIS

The systematic search yielded a total of 8 peer-reviewed publications as well as 10 literature reviews. Results show that cannabis consumption prior to exercise induces decrements in performance (reduced ability to maintain effort, physical/maximal work capacity), undesired physiological responses (increased heart and breathing rate as well as myocardial oxygen demand) and neurological effects on balance (increased sway).

CONCLUSIONS

Based on the articles included in this review, the authors conclude that cannabis consumption has an ergolytic effect on exercise performance and therefore does not act as a sport performance enhancing agent as raised by popular beliefs. Thus, cannabis consumption prior to exercise should be avoided in order to maximize performance in sports. Further research should mimic modern THC dosage (150 mg).

The heterogeneous effect of marijuana decriminalization policy on arrest rates in Philadelphia, Pennsylvania, 2009-2018

BACKGROUND

Marijuana decriminalization holds potential to reduce health inequities. However, limited attention has focused on assessing the impact of decriminalization policies across different populations. This study aims to determine the differential effect of a marijuana decriminalization policy change in Philadelphia, PA on marijuana arrests by demographic characteristics.

METHODS

Using a comparative interrupted time series design, we assessed whether the onset of marijuana decriminalization in Philadelphia County was associated with reduction in arrests rates from 2009 to 2018 compared to Dauphin County. Stratified models were used to describe the differential impact of decriminalization across different demographic populations.

RESULTS

Compared to Dauphin, the mean arrest rate for all marijuana-related crimes in Philadelphia declined by 19.9 per 100,000 residents (34.9% reduction), 17.1 per 100,000 residents (43.1% reduction) for possession, and 2.8 per 100,000 resident (15.9% reduction) for sales/manufacturing. Arrest rates also differed by demographic characteristics post-decriminalization. Notably, African Americans had a greater absolute/relative reduction in possession-based arrests than Whites. However, relative reductions for sales/manufacturing-based arrests was nearly 3 times lower for African Americans. Males had greater absolute/relative reduction for possession-based arrests, but lower relative reduction for sales/manufacturing-based arrests compared to females. There were no substantial absolute differences by age; however, youths (vs. adults) experienced higher relative reduction in arrest rates.

CONCLUSIONS

Findings suggest an absolute/relative reduction for possession-based arrests post-decriminalization; however, relative disparities in sales/manufacturing-based arrests, specifically for African Americans, increased. More consideration towards the heterogeneous effect of marijuana decriminalization are needed given the unintended harmful effects of arrest on already vulnerable populations.

Associations Between Marijuana Use and Involuntary Job Loss in the United States: Representative Longitudinal and Cross-Sectional Samples

OBJECTIVE

To investigate whether marijuana use is associated with involuntary job loss.

METHODS

Multivariable survey logistic analysis of longitudinal (2001 to 2002/2003 to 2004) and cross-sectional data (2012 to 2013) from National Epidemiologic Survey on Alcohol and Related Conditions (NESARC).

RESULTS

Marijuana use increased for all user groups with most workers who use marijuana using marijuana monthly (2.7% in 2001 to 2002 and 10.8% in 2012 to 2013). Past year marijuana users in 2001 to 2002 had higher odds of involuntary job loss in 2003 to 2004 (odds ratio [OR] 1.27; 95% confidence interval [CI] 1.13 to 1.41). Daily marijuana use is associated with higher odds of job loss in adjusted analyses using longitudinal (OR 2.18; 95%CI 1.71 to 2.77) and cross-sectional data (OR 1.40; 95%CI 1.06 to 1.86). Income significantly modifies these effects.

CONCLUSIONS

Findings indicate that job loss may be an overlooked social cost of marijuana use for US workers. Future studies using an occupational health perspective are needed.

A Survey Exploring the Relationship Between Cannabis Use Characteristics and Sexual Function in Men

Introduction

Cannabis is the most commonly used drug in the United States; however, the effects of cannabis use on male sexual function are poorly understood.

Aim

To characterize the contemporary landscape of cannabis use and to assess the associations between male sexual function and the frequency of use, the primary method of consumption, or cannabis chemovar (tetrahydrocannabinol or cannabidiol) among current users.

Methods

We surveyed adults who visited a single cannabis dispensary for baseline demographic information, medical history, cannabis use habits, and sexual function as assessed by the International Index of Erectile Function (IIEF). An IIEF-5 < 21 was considered erectile dysfunction.

Main Outcome Measures

The main outcome measure of the study was male sexual function via the IIEF domain scores.

Results

A total of 325 men completed the survey with a mean age of 46.7 years. 71.1% of the men were Caucasian and 52.6% were married. 13 men (4%) were never users; 29 men (8.9%) used 1–2 times/week; 51 men (15.7%) used 3–5 times/week, and 232 men (71.4%) used 6+ times/week. The average IIEF-5 score was 22.3 with 19.4% of the men having erectile dysfunction. In univariate analysis, men using cannabis more frequently had a higher overall IIEF (65.36 vs 60.52, P = .001), erectile domain (27.32 vs 25.74, P = .03), orgasm domain (9.08 vs 8.12, P < .001), intercourse satisfaction domain (12.42 vs 11.31, P = .006), and overall satisfaction domain (8.11 vs 7.05, P = .002). In multivariable analysis, compared to men who used cannabis 0 times/week, those who used 6 times/week had an increased overall IIEF (69.08 vs 64.64, P-value adjusted = 0.02), intercourse satisfaction domain (P-value adjusted = 0.04), and overall satisfaction domain (P-value adjusted = 0.02). The primary method of consumption (eg, smoking, edibles, etc.) and cannabinoid composition (eg, cannabidiol vs tetrahydrocannabinol dominant) were not associated with sexual function.

Conclusion

We report an association between the increased frequency of cannabis use and increased male sexual function. However, while the increased frequency of use was statistically significant with regard to the IIEF scores, the clinical significance of this is likely low, and selection bias may limit the generalizability of these findings. The method of consumption and cannabis chemovar were not associated with sexual function.

Bhambhvani HP, Kasman AM, Wilson-King G, et al. A Survey Exploring the Relationship Between Cannabis Use Characteristics and Sexual Function in Men. J Sex Med 2020;8:436–445.

Evaluation of Availability of Survey Data About Cannabis Use

IMPORTANCE

In response to increasing public support for cannabis legalization, understanding associations of state and federal policy changes related to cannabis legalization with patterns of cannabis use is important. A challenge for public health monitoring and research is significant variation in data availability related to cannabis use behaviors and perceptions across and within states and over time, including the availability of prelegalization vs postlegalization data.

OBJECTIVE

To review data available on cannabis use and related behaviors over time in Massachusetts and the US.

DESIGN, SETTING, AND PARTICIPANTS

This case series examined state and national surveys on public health and related behaviors and outcomes to review availability of cannabis-related data for Massachusetts for 8 key indicators over time. Additionally, the Behavioral Risk Factor Surveillance System (BRFSS) and Youth Risk Behavior Surveillance System for all states were reviewed. The analysis was conducted between February 1, 2019, and March 18, 2020.

EXPOSURES

Surveys that enable state-level estimation of cannabis use and related behaviors.

MAIN OUTCOMES AND MEASURES

Eight key indicators related to cannabis use behaviors and perceptions: lifetime cannabis use, age of initiation, frequency of use, location of use, method of use, source of cannabis, perceptions of cannabis, and reason for use (ie, medical vs nonmedical).

RESULTS

There were 7 surveys that monitored cannabis use and related behaviors in Massachusetts for adolescents and adults. No surveys monitored all 8 indicators of interest, and availability over time was limited. In the most recent BRFSS, 24 states asked cannabis-related questions, meaning BRFSS data on cannabis use was lacking for more than half of the US adult population. In the Youth Risk Behavior Surveillance System, 36 states asked standard cannabis questions; most other states had at least 1 question related to cannabis use and frequency.

CONCLUSIONS AND RELEVANCE

These findings of limitations of existing surveys, and particularly the lack of national questions in the BRFSS and Youth Risk Behavior Surveillance System, suggest that available data have substantial limitations for monitoring cannabis use. As cannabis policy changes continue, there is a need to remain focused on the availability of high-quality data sources that allow for critical public health research.

Marijuana use trends among college students in states with and without legalization of recreational use: initial and longer-term changes from 2008 to 2018

BACKGROUND AND AIMS

Young adult college students in the United States are likely to be affected by marijuana liberalization trends. However, changes in students' marijuana use following recreational marijuana legalization (RML) have not been examined in more than one RML state at a time, or beyond 1-2 years post-legalization.

DESIGN

Cross-sectional National College Health Assessment survey administered twice yearly from 2008 to 2018.

SETTING

A total of 587 4-year colleges and universities in 48 US states.

PARTICIPANTS

Undergraduates aged 18-26 years attending college in US states that did (n = 234 669 in seven states) or did not (n = 599 605 in 41 states) enact RML between 2008 and 2018.

MEASUREMENTS

Self-reported marijuana use (past 30 days) and individual and contextual covariates, institution-provided institutional and community covariates and publicly available dates when states enacted RML.

FINDINGS

Adjusting for covariates, state differences and state-specific linear time trends (accounting for pre-RML trends), prevalence of 30-day marijuana use increased more among students exposed to RML [odds ratio (OR) = 1.23, 95% confidence interval (CI) = 1.19-1.28, P < 0.001] than among non-RML state students throughout the same time-period; the results were similar for frequent use (≥ 20 days) (OR = 1.18, 95% CI = 1.10-1.27, P < 0.001). Interaction models supported stronger RML effects among students who were female, residing off-campus and aged 21 years and older; sexual orientation did not moderate RML effects. In the earliest states to enact RML (2012) there were increases in use prevalence in the second through the sixth year post-RML compared to pre-RML. In the second legalization group (2015) there were increases in the first and second year post-RML, and greater increases in the third year. In the later states (2016-17), increases were observed in both years after RML.

CONCLUSIONS

In US states that enacted recreational marijuana legislation from 2012 to 2017 there was evidence for a general trend towards greater increases in marijuana use by college students and differential impact by gender, legal using age and campus residence.

Psychosocial Determinants to Prenatal Marijuana Use Among a National Sample of Pregnant Females: 2015–2018

Marijuana use continues to be rampant among pregnant females. This study sought to examine recent marijuana use among a national sample of pregnant females. Aggregated data from the 2015–2018 National Survey on Drug Use and Health were utilized. Weighted analyses revealed that 5.19% of females used marijuana in the past 30 days. Those at greatest risk for recent use were African American (adjusted odds ratio [aOR]: 1.91); identified as gay/lesbian (aOR: 11.9) or bisexual (aOR: 3.37); used cigarettes (aOR: 2.74), alcohol (aOR: 5.10), and/or illicit drugs in the past month (aOR: 4.52); and thought marijuana was easy to access (aOR: 7.23). Women at decreased risk were older, Native Hawaiian, in their second trimester, and thought marijuana was a great risk. We believe our findings can inform harm-reduction efforts and inform prevention messages.

Cannabinomics: Application of Metabolomics in Cannabis (Cannabis sativa L.) Research and Development

Cannabis (Cannabis sativa L.) is a complex, polymorphic plant species, which produces a vast array of bioactive metabolites, the two major chemical groups being cannabinoids and terpenoids. Nonetheless, the psychoactive cannabinoid tetrahydrocannabinol (Δ 9 -THC) and the non-psychoactive cannabidiol (CBD), are the two major cannabinoids that have monopolized the research interest. Currently, more than 600 Cannabis varieties are commercially available, providing access to a multitude of potent extracts with complex compositions, whose genetics are largely inconclusive. Recently introduced legislation on Cannabis cultivation in many countries represents a great opportunity, but at the same time, a great challenge for Cannabis research and development (R&D) toward applications in the pharmaceutical, food, cosmetics, and agrochemical industries. Based on its versatility and unique capabilities in the deconvolution of the metabolite composition of complex matrices, metabolomics represents an ideal bioanalytical tool that could greatly assist and accelerate Cannabis R&D. Among others, Cannabis metabolomics or cannabinomics can be applied in the taxonomy of Cannabis varieties in chemovars, the research on the discovery and assessment of new Cannabis-based sources of bioactivity in medicine, the development of new food products, and the optimization of its cultivation, aiming for improvements in yield and potency. Although Cannabis research is still in its infancy, it is highly foreseen that the employment of advanced metabolomics will provide insights that could assist the sector to face the aforementioned challenges. Within this context, here, the current state-of-the-art and conceptual aspects of cannabinomics are presented.

Cannabis use among U.S. adolescents in the era of marijuana legalization: a review of changing use patterns, comorbidity, and health correlates

Decriminalization, medicalization, and legalization of cannabis use by a majority of U.S. states over the past 25 years have dramatically shifted societal perceptions and use patterns among Americans. How marijuana policy changes have affected population-wide health of U.S. youth and what the downstream public health implications of marijuana legalization are topics of significant debate. Cannabis remains the most commonly used federally illicit psychoactive drug by U.S. adolescents and is the main drug for which U.S. youth present for substance use treatment. Converging evidence indicates that adolescent-onset cannabis exposure is associated with short- and possibly long-term impairments in cognition, worse academic/vocational outcomes, and increased prevalence of psychotic, mood, and addictive disorders. Odds of negative developmental outcomes are increased in youth with early-onset, persistent, high frequency, and high-potency Δ-9-THC cannabis use, suggesting dose-dependent relationships. Cannabis use disorders are treatable conditions with clear childhood antecedents that respond to targeted prevention and early intervention strategies. This review indicates that marijuana policy changes have had mixed effects on U.S. adolescent health including potential benefits from decriminalization and negative health outcomes evidenced by increases in cannabis-related motor vehicle accidents, emergency department visits, and hospitalizations. Federal and state legislatures should apply a public health framework and consider the possible downstream effects of marijuana policy change on paediatric health.

Comprehensive characterization of mainstream marijuana and tobacco smoke

Recent increases in marijuana use and legalization without adequate knowledge of the risks necessitate the characterization of the billions of nanoparticles contained in each puff of smoke. Tobacco smoke offers a benchmark given that it has been extensively studied. Tobacco and marijuana smoke particles are quantitatively similar in volatility, shape, density and number concentration, albeit with differences in size, total mass and chemical composition. Particles from marijuana smoke are on average 29% larger in mobility diameter than particles from tobacco smoke and contain 3.4× more total mass. New measurements of semi-volatile fractions determine over 97% of the mass and volume of the particles from either smoke source are comprised of semi-volatile compounds. For tobacco and marijuana smoke, respectively, 4350 and 2575 different compounds are detected, of which, 670 and 536 (231 in common) are tentatively identified, and of these, 173 and 110 different compounds (69 in common) are known to cause negative health effects through carcinogenic, mutagenic, teratogenic, or other toxic mechanisms. This study demonstrates striking similarities between marijuana and tobacco smoke in terms of their physical and chemical properties.

Can Hemp Help? Low-THC Cannabis and Non-THC Cannabinoids for the Treatment of Cancer

Cannabis has been used to relieve the symptoms of disease for thousands of years. However, social and political biases have limited effective interrogation of the potential benefits of cannabis and polarised public opinion. Further, the medicinal and clinical utility of cannabis is limited by the psychotropic side effects of ∆⁹-tetrahydrocannabinol (∆⁹-THC). Evidence is emerging for the therapeutic benefits of cannabis in the treatment of neurological and neurodegenerative diseases, with potential efficacy as an analgesic and antiemetic for the management of cancer-related pain and treatment-related nausea and vomiting, respectively. An increasing number of preclinical studies have established that ∆⁹-THC can inhibit the growth and proliferation of cancerous cells through the modulation of cannabinoid receptors (CB1R and CB2R), but clinical confirmation remains lacking. In parallel, the anti-cancer properties of non-THC cannabinoids, such as cannabidiol (CBD), are linked to the modulation of non-CB1R/CB2R G-protein-coupled receptors, neurotransmitter receptors, and ligand-regulated transcription factors, which together modulate oncogenic signalling and redox homeostasis. Additional evidence has also demonstrated the anti-inflammatory properties of cannabinoids, and this may prove relevant in the context of peritumoural oedema and the tumour immune microenvironment. This review aims to document the emerging mechanisms of anti-cancer actions of non-THC cannabinoids.

Medical cannabis as an alternative therapeutics for Parkinsons' disease: Systematic review

OBJECTIVES

1) to evaluate the efficacy of medical cannabinoids (MC) by appraising the quality of evidence from clinical studies 2) to explore the factors hampering the MC use in clinical practice of Parkinson's disease (PD).

METHODS

We performed a systematic review through various databases. The quality of 14 studies was assessed by Cochrane risk bias (5 randomized controlled trials- RCT) and Newcastle-Ottawa scale (9 uncontrolled studies).

RESULTS

The positive effects on motor (5 studies) and non-motor symptoms (4 studies) described in uncontrolled studies have not been confirmed by the few and small RCTs. Only one RCT found a reduction of levodopa-induced dyskinesias, another a reduction in anxiety and tremor amplitude in an anxiogenic situation, while the remaining three without effect on motor/non-motor symptoms. Physical and psychological symptoms are among the most common side effects.

CONCLUSIONS

There is insufficient evidence to reform international legislation regarding cannabis use in PD practice.

Race/Ethnicity Differences in Trends of Marijuana, Cigarette, and Alcohol Use Among 8th, 10th, and 12th Graders in Washington State, 2004-2016

Accurate estimates of substance use in the teenage years by race/ethnicity may help identify when to intervene to prevent long-term substance use disparities. We examined trends in past 30-day use of marijuana, cigarette, and alcohol among 8th, 10th, and 12th graders in Washington State, which passed a recreational marijuana law in 2012 and initiated retail marijuana sales in 2014. Data are from the 2004-2016 Washington Healthy Youth Surveys (n = 161,992). We used time series regression models to assess linear and quadratic trends in substance use for the full sample and stratified on race/ethnicity and grade level and examined relative differences in prevalence of use by race/ethnicity. In Washington, across all racial/ethnic groups, marijuana use peaked in 2012. Although there was not a significant overall change in marijuana use for the full sample across the study period, there was a statistically significant increase in use among 12th graders and a statistically significant decrease among 8th graders. Relative to Whites, Asians had a lower prevalence of marijuana use, whereas all other race/ethnicity groups had a higher prevalence of use. Prevalence of marijuana use is particularly high among American Indian/Alaska Native and Black youth and has increased most rapidly among 12th grade Hispanic/Latinx youth. There were large and statistically significant decreases in alcohol and cigarette use across the study period for the full sample, as well as for each race/ethnicity group. These findings highlight the need for continued monitoring of trends in use among these groups and potentially warrant consideration of selective interventions that specifically focus on students of color and that include developmentally-appropriate strategies relevant to each grade.

Guidelines for public health and safety metrics to evaluate the potential harms and benefits of cannabis regulation in Canada

ISSUES

Canada recently introduced a public health-based regulatory framework for non-medical cannabis. This review sought to identify a comprehensive set of indicators to evaluate the public health and safety impact of cannabis regulation in Canada, and to explore the ways in which these indicators may be expected to change in the era of legal non-medical cannabis.

APPROACH

Five scientific databases were searched to compile a list of cannabis-related issues of interest to public health and safety. A set of indicators was developed based on topics and themes that emerged. Preliminary evidence from other jurisdictions in the USA and Canada that have legalised medical and/or non-medical cannabis (e.g. Colorado, Washington) was summarised for each indicator, wherever possible.

KEY FINDINGS

In total, 28 indicators were identified under five broad themes: public safety; cannabis use trends; other substance use trends; cardiovascular and respiratory health; and mental health and cognition. Preliminary trends from other legalised jurisdictions reveal little consensus regarding the effect of cannabis legalisation on public health and safety harms and an emerging body of evidence to support potential benefits (e.g. reductions in opioid use and overdose).

IMPLICATIONS

In addition to indicators of commonly discussed challenges (e.g. cannabis-related hospitalisations, cannabis-impaired driving), this review led to the recommendation of several indicators to monitor for possible public health and safety improvements.

CONCLUSION

In preparing a comprehensive public health and safety monitoring and evaluation system for cannabis regulation, this review underscores the importance of not only measuring the possible risks but also the potential benefits.

Association Between Recreational Marijuana Legalization in the United States and Changes in Marijuana Use and Cannabis Use Disorder From 2008 to 2016

IMPORTANCE

Little is known about changes in marijuana use and cannabis use disorder (CUD) after recreational marijuana legalization (RML).

OBJECTIVES

To examine the associations between RML enactment and changes in marijuana use, frequent use, and CUD in the United States from 2008 to 2016.

DESIGN, SETTING, AND PARTICIPANTS

This survey study used repeated cross-sectional survey data from the National Survey on Drug Use and Health (2008-2016) conducted in the United States among participants in the age groups of 12 to 17, 18 to 25, and 26 years or older.

INTERVENTIONS

Multilevel logistic regression models were fit to obtain estimates of before-vs-after changes in marijuana use among respondents in states enacting RML compared to changes in other states.

MAIN OUTCOMES AND MEASURES

Self-reported past-month marijuana use, past-month frequent marijuana use, past-month frequent use among past-month users, past-year CUD, and past-year CUD among past-year users.

RESULTS

The study included 505 796 respondents consisting of 51.51% females and 77.24% participants 26 years or older. Among the total, 65.43% were white, 11.90% black, 15.36% Hispanic, and 7.31% of other race/ethnicity. Among respondents aged 12 to 17 years, past-year CUD increased from 2.18% to 2.72% after RML enactment, a 25% higher increase than that for the same age group in states that did not enact RML (odds ratio [OR], 1.25; 95% CI, 1.01-1.55). Among past-year marijuana users in this age group, CUD increased from 22.80% to 27.20% (OR, 1.27; 95% CI, 1.01-1.59). Unmeasured confounders would need to be more prevalent in RML states and increase the risk of cannabis use by 1.08 to 1.11 times to explain observed results, indicating results that are sensitive to omitted variables. No associations were found among the respondents aged 18 to 25 years. Among respondents 26 years or older, past-month marijuana use after RML enactment increased from 5.65% to 7.10% (OR, 1.28; 95% CI, 1.16-1.40), past-month frequent use from 2.13% to 2.62% (OR, 1.24; 95% CI, 1.08-1.41), and past-year CUD from 0.90% to 1.23% (OR, 1.36; 95% CI, 1.08-1.71); these results were more robust to unmeasured confounding. Among marijuana users in this age group, past-month frequent marijuana use and past-year CUD did not increase after RML enactment.

CONCLUSIONS AND RELEVANCE

This study's findings suggest that although marijuana legalization advanced social justice goals, the small post-RML increase in risk for CUD among respondents aged 12 to 17 years and increased frequent use and CUD among adults 26 years or older in this study are a potential public health concern. To undertake prevention efforts, further studies are warranted to assess how these increases occur and to identify subpopulations that may be especially vulnerable.

Temporal Changes in the Cross-Sectional Associations between Cannabis Use, Suicidal Ideation, and Depression in a Nationally Representative Sample of Canadian Adults in 2012 Compared to 2002

BACKGROUND

With the recent legalization of nonmedical cannabis in Canada, it is important to document previous associations between cannabis use and major depressive episode and suicidal ideation, as well as the extent to which these associations have changed over time.

METHODS

This study uses pooled data from the 2002 and 2012 Canadian Community Health Survey's Mental Health Component, which are repeated cross-sectional surveys of nationally representative samples of Canadians 15 to 60 years of age (n = 43,466). Binary logistic regression was performed, applying weighting and bootstrapping, to examine the association between at least monthly use of cannabis and past 12-month suicidal ideation and major depressive episode (MDE).

RESULTS

At least monthly nonmedical cannabis use was associated with an increased odds of MDE and suicidal ideation, and both associations strengthened in 2012 compared to 2002. Canadians using cannabis at least once a month in 2012 had 1.59 (95% confidence interval [CI], 1.11 to 2.27) times the odds of experiencing suicidal ideation and 1.55 (95% CI, 1.12 to 2.13) times the odds of experiencing MDE compared to those who used cannabis at least once a month in 2002. This temporal change remained after controlling for other substance use.

CONCLUSIONS

Monthly cannabis use was consistently related to both suicidal ideation and MDE, and these associations were stronger in 2012 compared to 2002. The findings of this study provide a baseline for the association between cannabis use and suicide and depression in the Canadian population that should be reevaluated now that nonmedical cannabis has been legalized.

Changes in alcohol and cigarette consumption in response to medical and recreational cannabis legalization: Evidence from U.S. state tax receipt data

BACKGROUND

Whether medical or recreational cannabis legalization impacts alcohol or cigarette consumption is a key question as cannabis policy evolves, given the adverse health effects of these substances. Relatively little research has examined this question. The objective of this study was to examine whether medical or recreational cannabis legalization was associated with any change in state-level per capita alcohol or cigarette consumption.

METHODS

Dependent variables included per capita consumption of alcohol and cigarettes from all 50 U.S. states, estimated from state tax receipts and maintained by the Centers for Disease Control and National Institute for Alcohol Abuse and Alcoholism, respectively. Independent variables included indicators for medical and recreational legalization policies. Three different types of indicators were separately used to model medical cannabis policies. Indicators for the primary model were based on the presence of active medical cannabis dispensaries. Secondary models used indicators based on either the presence of a more liberal medical cannabis policy ("non-medicalized") or the presence of any medical cannabis policy. Difference-in-difference regression models were applied to estimate associations for each type of policy.

RESULTS

Primary models found no statistically significant associations between medical or recreational cannabis legalization policies and either alcohol or cigarette sales per capita. In a secondary model, both medical and recreational policies were associated with significantly decreased per capita cigarette sales compared to states with no medical cannabis policy. However, post hoc analyses demonstrated that these reductions were apparent at least two years prior to policy adoption, indicating that they likely result from other time-varying characteristics of legalization states, rather than cannabis policy.

CONCLUSION

We found no evidence of a causal association between medical or recreational cannabis legalization and changes in either alcohol or cigarette sales per capita.

Early evidence of the impact of cannabis legalization on cannabis use, cannabis use disorder, and the use of other substances: Findings from state policy evaluations

Background: The past decade has seen unprecedented shifts in the cannabis policy environment, and the public health impacts of these changes will hinge on how they affect patterns of cannabis use and the use and harms associated with other substances.Objectives: To review existing research on how state cannabis policy impacts substance use, emphasizing studies using methods for causal inference and highlighting gaps in our understanding of policy impacts on evolving cannabis markets.Methods: Narrative review of quasi-experimental studies for how medical cannabis laws (MCLs) and recreational cannabis laws (RCLs) affect cannabis use and use disorders, as well as the use of or harms from alcohol, opioids, and tobacco.Results: Research suggests MCLs increase adult but not adolescent cannabis use, and provisions of the laws associated with less regulated supply may increase adult cannabis use disorders. These laws may reduce some opioid-related harms, while their impacts on alcohol and tobacco use remain uncertain. Research on RCLs is just emerging, but findings suggest little impact on the prevalence of adolescent cannabis use, potential increases in college student use, and unknown effects on other substance use.Conclusions: Research on how MCLs influence cannabis use has advanced our understanding of the importance of heterogeneity in policies, populations, and market dynamics, but studies of how MCLs relate to other substance use often ignore these factors. Understanding effects of cannabis laws requires greater attention to differences in short- versus long-term effects of the laws, nuances of policies and patterns of consumption, and careful consideration of appropriate control groups.

Age, period and cohort effects in frequent cannabis use among US students: 1991-2018

BACKGROUND AND AIMS

As the legal status of cannabis changes across the United States and modes of administration expand, it is important to examine the potential impact on adolescent cannabis use. This study aimed to assess changes in prevalence of frequent cannabis use in adolescents in the United States and how far this varies by age and cohort.

DESIGN

Analysis of Monitoring the Future, a nationally representative annual survey of 8th-, 10th- and 12th-grade students in the United States conducted from 1991 to 2018.

SETTING

In-school surveys completed by US adolescents.

PARTICIPANTS

A total of 1 236 159 8th-, 10th- and 12th-graders; 51.5% female, 59.6% non-Hispanic white, 12.3% non-Hispanic black, 13.4% Hispanic and 14.7% other race/ethnicity.

MEASUREMENTS

Frequent cannabis use (FCU), defined as six or more occasions in the past 30 days, stratified by sex, race/ethnicity and parental education.

FINDINGS

FCU among US adolescents increased over the study period; the peak in 2010-18 was 11.4% among 18-year-old students. This increase was best explained by both period and cohort effects. Compared with respondents in 2005, adolescents surveyed in 2018 had period effects in FCU that were 1.6 times greater. Adolescents in younger birth cohorts (those born > 1988) had a lower increase in FCU than those born prior to 1988. Results were consistent across sex, parent education and race/ethnicity, with period effects indicating increasing FCU after 2005 and cohort effects indicating a lower magnitude of increase in more recent birth cohorts. Age and parental education disparities in FCU have increased over time, whereas race/ethnicity differences have converged over time; black students were 0.67 [95% confidence interval (CI) = 0.64-0.70] times as likely to use cannabis frequently as white students from 1991 to 2000, and 1.03 (95% CI = 0.98-1.09) times as likely from 2011 to 2018 (P-value for time interaction < 0.001).

CONCLUSIONS

The prevalence of frequent cannabis use (FCU) increased from 1991 to 2018 among older adolescents in the United States. Racial/ethnic differences in FCU converged, whereas parental education differences have diverged.

Shared and specific associations of substance use disorders on adverse outcomes: A national prospective study

BACKGROUND AND AIMS

Substance use disorders (SUD) frequently co-occur and are associated with numerous adverse outcomes and lower quality of life. The goal of this study was to examine whether the associations of SUD with adverse outcomes occur through a shared liability or are disorder-specific even after taking into account their frequent co-occurrence.

BASIC PROCEDURES

Data were drawn from the National Epidemiological Survey on Alcohol and Related Conditions. The association between nine SUDs assessed at Wave 1 (2001-2002) and a broad range of outcomes (divorce/separation, violence, unemployment, financial crisis, legal problems, problems with a neighbor, friend, or relative, and quality of life) at Wave 2 (2005-2005) were estimated separately and simultaneously using a latent variable model to account for their co-occurrence and identify potential disorder-specific effects.

MAIN FINDINGS

SUD at Wave 1 were associated with increased prevalence of all adverse outcomes at Wave 2 (p < .05). With the exception of nicotine dependence and tranquilizer use disorder, we found no specific associations of any SUD with any adverse outcome. Rather, associations occurred primarily through the latent variable representing the shared effects of the different SUDs.

CONCLUSIONS AND RELEVANCE

Our findings underscore the importance of adopting dimensional approaches to model the co-occurrence of SUD. Because SUD increases the risk of adverse outcomes mainly through a general predisposition representing mechanisms shared across SUD rather than through drug-specific mechanisms, this dimension should be considered as a therapeutic target to substantially advance prevention of adverse outcomes caused by SUD.

Dissociation between the growing opioid demands and drug policy directions among the U.S. older adults with degenerative joint diseases

We aim to examine temporal trends of orthopedic operations and opioid-related hospital stays among seniors in the nation and states of Oregon and Washington where marijuana legalization was accepted earlier than any others.As aging society advances in the United States (U.S.), orthopedic operations and opioid-related hospital stays among seniors increase in the nation.A serial cross-sectional cohort study using the healthcare cost and utilization project fast stats from 2006 through 2015 measured annual rate per 100,000 populations of orthopedic operations by age groups (45-64 vs 65 and older) as well as annual rate per 100,000 populations of opioid-related hospital stays among 65 and older in the nation, Oregon and Washington states from 2008 through 2017. Orthopedic operations (knee arthroplasty, total or partial hip replacement, spinal fusion or laminectomy) and opioid-related hospital stays were measured. The compound annual growth rate (CAGR) was used to quantify temporal trends of orthopedic operations by age groups as well as opioid-related hospital stays and was tested by Rao-Scott correction of χ for categorical variables.The CAGR (4.06%) of orthopedic operations among age 65 and older increased (P < .001) unlike the unchanged rate among age 45 to 64. The CAGRs of opioid-related hospital stays among age 65 and older were upward trends among seniors in general (6.79%) and in Oregon (10.32%) and Washington (15.48%) in particular (all P < .001).Orthopedic operations and opioid-related hospital stays among seniors increased over time in the U.S. Marijuana legalization might have played a role of gateway drug to opioid among seniors.

Alcohol, tobacco, and marijuana consumption is associated with increased odds of same-day substance co- and tri-use

BACKGROUND

Little is known about event-level patterns of marijuana co- or tri-use with alcohol and tobacco. Thus, the study goal was to examine patterns of same-day alcohol, cigarette, and marijuana co- and tri-use at the individual level in non-treatment-seeking alcohol users.

METHODS

Participants (N = 551) completed an in-person interview for alcohol, cigarette, and marijuana use over the previous 30 days, and the event-level substance use patterns of n = 179 participants who reported using each of these substances at least once per month were analyzed.

RESULTS

The use of alcohol, marijuana, or cigarettes independently increased the probability of subsequent, simultaneous co-use of one of the two remaining substances. The co-use of alcohol with cigarettes and marijuana with cigarettes produced generally additive effects on the odds of same day tri-use of marijuana and alcohol, respectively. Conversely, the co-use of alcohol and marijuana produced sub-additive effects on likelihood of cigarette use. Sex moderated several of the observed patterns of co- and tri-use: the relationship between alcohol or cigarette use predicting marijuana co-use was stronger in men, whereas the observed additive relationships between drug co-use leading to tri-use was stronger in women.

CONCLUSIONS

The presented results may aid in the understanding of how simultaneous co-use of marijuana with alcohol and/or tobacco relates to the etiology, maintenance, and treatment of comorbid and trimorbid substance use disorder. Replication and extension of the results in treatment seeking populations using more fine-grained analysis approaches, e.g. ecological momentary assessment, is needed.

Greater risk for frequent marijuana use and problems among young adult marijuana users with a medical marijuana card

BACKGROUND

This study compared young adults with and without a medical marijuana (MM) recommendation from a provider ("MM card") on their developmental trajectories of frequent marijuana use and marijuana-related problems in young adulthood.

METHODS

The analytic sample consists of young adult past month marijuana users (N = 671) who were part of a larger, diverse, and predominantly California cohort. Analyses are based on data from seven surveys completed from ages 13-19.

RESULTS

At age 19, 28% of participants reported having an MM card to legally purchase marijuana from an MM dispensary. A multiple group latent growth model indicated that young adults who had an MM card showed steeper increases in frequent marijuana use (i.e., 20-30 days of use in the past month) from ages 13-19 compared to young adults who did not have an MM card. Logistic regression models that matched MM cardholders and non-MM cardholders on individual sociodemographic characteristics found that MM cardholders were more likely to report marijuana negative consequences, selling marijuana/hashish, and driving under the influence of marijuana in the past year. In addition, MM cardholders were more likely to have tried cutting down or quitting in the past 3-months.

CONCLUSIONS

Among young adult marijuana users, those with an MM card had a higher risk profile for marijuana use and related problems compared to those without an MM card. Given expanding state legalization of MM, this issue warrants further attention.