National Estimates of Marijuana Use and Related Indicators - National Survey on Drug Use and Health, United States, 2002-2014

Trends in alcohol and marijuana detected in homicide victims in 9 US states: 2004-2016

Background

Use of alcohol and other drugs is a major risk factor for assaultive injuries and violent deaths. The purpose of this study was to examine the time trends in the prevalence of alcohol and marijuana detected in homicide victims.

Methods

We analyzed toxicological testing data for homicide victims (n = 12,638) from the 2004–2016 National Violent Death Reporting System in 9 US states (Colorado, Georgia, Massachusetts, New Jersey, Oregon, Rhode Island, South Carolina, Virginia, and Wisconsin). We used the Cochran-Armitage test for trend to assess the statistical significance of changes in the prevalence of alcohol and marijuana detected in these homicide victims during the study period.

Results

Overall, 37.5% of the homicide victims tested positive for alcohol, 31.0% positive for marijuana, and 11.4% positive for both substances. During the study period, the prevalence of marijuana increased from 22.3% (95% confidence interval [CI] = 19.6, 25.0) in 2004 to 42.1% (95% CI = 39.2, 44.9) in 2016 (Z = -15.7; P < .001) while the prevalence of alcohol declined slightly (Z = 1.5; P = 0.143). Marked increases in the prevalence of marijuana were observed in both sexes and across age and racial groups.

Conclusions

Marijuana is increasingly detected in homicide victims irrespective of demographic characteristics. Further research is needed to assess the causal role of marijuana use and concurrent use of marijuana and alcohol in homicide victimization.

Systematic Review of Cannabis Use and Risk of Occupational Injury

Aim: A range of nations, including countries of the European Union, Australia, and the Americas have recently implemented or proposed reforms to how they control cannabis use, thereby departing from traditional approaches of criminal prohibition that have dominated throughout most of the twentieth century. Given these policy developments and the widespread global use of cannabis, it is critically important to understand the possible risks associated with cannabis use in relation to major societal harms. Methods: This systematic review investigates the potential link between cannabis use and occupational injury. Consequently, it appraises all available current literature from five databases, following Cochrane and PRISMA guidelines. Results: Seven of the 16 reviewed studies show evidence supporting a positive association between cannabis use and occupational injury. One study shows evidence supporting a negative association and the remaining eight studies show no evidence of a significant relation. None of the studies assessed cannabis-related impairment. Only three of the reviewed studies show clear evidence that cannabis use preceded the occupational-injury event. Conclusion: The current body of evidence does not provide sufficient evidence to support the position that cannabis users are at increased risk of occupational injury. Further, the study quality assessment suggests significant biases in the extant literature are present due to potential confounding variables, selection of participants, and measurement of exposures and outcomes. Future high-quality evidence will be needed to elucidate the relation between cannabis use and occupational injury.

Pharmacotherapies for Cannabis Use Disorders: Clinical Challenges and Promising Therapeutic Agents

This chapter reviews pharmacotherapies that have been trialled for cannabis dependence, identifying those that warrant further research and those of little or uncertain value. A diverse range of medicines have been tested, representing a broad range of pharmacological strategies. These include tetrahydrocannabinol preparations, various types of antidepressant, anxiolytics, a glutamatergic modulator and the neuropeptide oxytocin. Cannabinoid agonists warrant further research. For the FAAH inhibitor PF-04457845, oxytocin, varenicline and gabapentin, although there is a signal to indicate further research is warranted, these medications do not yet have sufficient evidence to support clinical use, and larger, longer-term trials are needed in representative treatment-seeking populations. Special populations that warrant consideration are those with cannabis dependence and concurrent mental health conditions and those that develop dependence through therapeutic use.

Sources of Information and Beliefs About the Health Effects of Marijuana

BACKGROUND

Marijuana is currently legal for recreational use in 10 states and Washington DC while a total of 34 states have implemented varying degrees of medical marijuana. The commercialization of marijuana has been accompanied by a proliferation of false claims regarding the therapeutic potential of marijuana, which are popularized by several different information sources. To date, no study has examined where US adults get their information regarding marijuana.

OBJECTIVE

To determine the sources of information associated with believing unsupported claims about marijuana.

DESIGN

Probability-based online survey PARTICIPANTS: 16,820 adults, with a response rate of about 55% (N = 9003) MAIN MEASURES: Most influential sources of information about marijuana and belief of statements consistent with misinformation, for example, smoking marijuana has preventative health benefits, secondhand marijuana smoke or use during pregnancy is completely or somewhat safe, and marijuana is not at all addictive.

KEY RESULTS

There were 9003 respondents (response rate 55%). Forty-three percent believed unsupported claims about marijuana. The most influential sources of information were health professionals, traditional media, friends/relatives, and social media/internet. Individuals reporting social media or the Internet (1.46 CI [1.30, 1.64]), the marijuana industry (e.g., advertisements, dispensaries) (2.88 CI [2.15, 3.88]), and friends or relatives (1.41 CI[1.26, 1.58]) as the most influential source of information about marijuana were more likely to believe any statement consistent with misinformation about marijuana in comparison with those who reported other sources as most influential.

CONCLUSIONS

Individuals reporting the most significant source of information regarding marijuana was from social media or the Internet, the marijuana industry, or friends or relatives were more likely to believe unsupported claims about marijuana. Public health campaigns to counter the misinformation about marijuana to the public are needed.

Gambling and Cannabis Use: Clinical and Policy Implications

Eleven US States and the District of Columbia legally allow personal (i.e., recreational) cannabis use by adults, and an additional 22 states allow use of cannabis for medicinal purposes. Of these jurisdictions, only two do not have some form of legalized gambling available (https://www.casino.org/local/guide/). In contrast to this rapid increase in legally available marijuana is the limited knowledge about the intersection of cannabis use and gambling. This paper strives to define the current status of the relevant literatures and consider the implication for future gambling research. We describe the research literature on the prevalence of cannabis use and co-existing gambling problems and the effects of cannabis use on gambling-related cognitive functions and decision-making. We also discuss clinical considerations with treating problem gamblers with a cannabis use disorder. Finally, the potential implications for responsible gambling practices and policies and the most pressing gaps in the research literature are offered.

Priming primary care providers to engage in evidence-based discussions about cannabis with patients

Cannabis use has become increasingly common in the U.S. in recent years, with legalization for medical and recreational purposes expanding to more states. With this increase in use and access, providers should be prepared to have more conversations with patients about use. This review provides an overview of cannabis terminology, pharmacology, benefits, harms, and risk mitigation strategies to help providers engage in these discussions with their patients. Current evidence for the medical use of cannabis, cannabis-related diagnoses including cannabis use disorder (CUD) and withdrawal syndromes, and the co-use of opioids and cannabis are discussed. It is crucial that providers have the tools and information they need to deliver consistent, evidence-based assessment, treatment, prevention and harm-reduction, and we offer practical guidance in these areas.

Trends in marijuana edible consumption and perceptions of harm in a cohort of young adults

BACKGROUND

Rates of marijuana legalization have increased rapidly in recent years resulting in the marketing of alternative products like edibles that do not involve inhaling smoke. Edibles however pose unique public health challenges due to their greater risk for over-intoxication.

METHODS

1858 young adults were surveyed every six months from 2016 to 2018. Logistic regression models examined trends in use and perceptions of harm. Chi-squared tests compared demographic and behavioral characteristics of edible users and non-users by frequency of marijuana use.

RESULTS

Perceptions of no harm from edibles increased (25.4%, 27.3%, 26.7%, 28.4%, 29.6%; p = 0.006) while it declined for smoking marijuana (12.2%, 13.5%, 11.7%, 10.6%, 9.1%; p < 0.001). Among non-daily marijuana users, edible use increased (20.3%, 24.8%, 30.5%, 36.2%, 36.6%; p < 0.001) while smoking marijuana declined for both daily and non-daily users. Among daily users, edible users were more likely to use all modes of consumption than non-edible users. Among non-daily users, edible users were less likely to smoke marijuana and perceive harm from edibles and were more likely to perceive harm from smoking marijuana and have visited a dispensary than non-edible users.

CONCLUSIONS

Edibles are increasingly consumed and perceived to not be harmful, despite the greater danger of over-intoxication. However, daily use of edibles alone is uncommon. The finding that edible users were more likely to have visited a dispensary provides a potential intervention point for consumer education. Strong scientific evidence is needed to guide policymakers in best practices for communicating knowledge and potential harms of these products.

Cannabis use disorder among people using cannabis daily/almost daily in the United States, 2002-2016

BACKGROUND

Cannabis use disorder (CUD) prevalence among people reporting past-year cannabis use declined from 2002-2016. We examined whether similar reductions in CUD were observed among people reporting daily/almost daily cannabis use. We expected that CUD prevalence among people reporting daily/almost daily use would not decrease.

METHODS

We used 2002-2016 National Survey on Drug Use and Health (NSDUH) data, including 22,651 individuals using cannabis 300+ days in the past year. CUD was defined using DSM-IV criteria for cannabis abuse and/or dependence. Age categories included: 12-17, 18-25, and 26 + . Annual prevalence of CUD, cannabis dependence, cannabis abuse, and each individual abuse/dependence items accounted for the complex survey design. Differences in trends over time were examined by age group.

RESULTS

From 2002-2016, the prevalence of CUD among people reporting daily/almost daily cannabis use decreased by 26.8% in adolescents, by 29.7% in ages 18-25, and by 37.5% in ages 26 + . Prevalence of DSM-IV cannabis dependence decreased significantly among adolescents (-43.9%) and young adults (-26.8%) but remained stable in adults 26 + . Reductions in most dependence items were observed in young adults, with less consistent patterns in adolescents and adults 26 + . Prevalence of DSM-IV cannabis abuse decreased overall and for each abuse item across all age groups.

CONCLUSIONS

Contrary to expectations, CUD prevalence decreased significantly across all ages reporting daily/almost daily cannabis use between 2002-2016. Cannabis dependence prevalence decreased for adolescents and young adults and was stable only among adults ages 26+ reporting daily/almost daily cannabis use. Potential drivers of this decrease should be further explored.

A Trend Analysis of Age of First Marijuana Use Among High School Students in the United States From 1991 to 2017

Background. Marijuana is the most commonly used illicit drug in the United States. There has been a rapidly changing marijuana policy environment and increased acceptability related to marijuana in the United States. How the changing environment will potentially influence adolescents age of initiation remains unknown. While much of extant literature has primarily focused on current marijuana use, less is known about age of first use. This study examined trends in adolescents' age of first marijuana use in the United States. Method. Data were drawn from the 1991 to 2017 Youth Risk Behavior Survey. We used linear regression for age of first use as a continuous variable, and logistic regression for marijuana use before the age of 15 years as a dichotomous variable. Joinpoint regression analysis identified where significant changes in trend occurred. Results. Results showed that the mean age of first marijuana use increased significantly between 1991 and 2017. Males had a younger age of first use than females. Between 1991 and 1997, there was an increasing trend in the prevalence of marijuana use before the age of 15 years in all adolescents and in subgroups for males, females, all races, and 9th and 10th grades. After 1997, a significant downward trend was found in all adolescents. Conclusions. Our results do not indicate an overall decreasing trend of age of first use among the general adolescent population. Results show a downward trend in the use of marijuana before the age of 15 years since 1997.

Association Between Marijuana Use and Risk of Cancer: A Systematic Review and Meta-analysis

Importance

Marijuana use is common and growing in the United States amid a trend toward legalization. Exposure to tobacco smoke is a well-described preventable cause of many cancers; the association of marijuana use with the development of cancer is not clear.

Objective

To assess the association of marijuana use with cancer development.

Data Sources

A search of PubMed, Embase, PsycINFO, MEDLINE, and the Cochrane Library was conducted on June 11, 2018, and updated on April 30, 2019. A systematic review and meta-analysis of studies published from January 1, 1973, to April 30, 2019, and references of included studies were performed, with data analyzed from January 2 through October 4, 2019.

Study Selection

English-language studies involving adult marijuana users and reporting cancer development. The search strategy contained the following 2 concepts linked together with the AND operator: marijuana OR marihuana OR tetrahydrocannabinol OR cannabinoid OR cannabis; AND cancer OR malignancy OR carcinoma OR tumor OR neoplasm.

Data Extraction and Synthesis

Two reviewers independently reviewed titles, abstracts, and full-text articles; 3 reviewers independently assessed study characteristics and graded evidence strength by consensus.

Main Outcomes and Measures

Rates of cancer in marijuana users, with ever use defined as at least 1 joint-year exposure (equivalent to 1 joint per day for 1 year), compared with nonusers. Meta-analysis was conducted if there were at least 2 studies of the same design addressing the same cancer without high risk of bias when heterogeneity was low to moderate for the following 4 cancers: lung, head and neck squamous cell carcinoma, oral squamous cell carcinoma, and testicular germ cell tumor (TGCT), with comparisons expressed as odds ratios (ORs) with 95% CIs.

Results

Twenty-five English-language studies (19 case-control, 5 cohort, and 1 cross-sectional) were included; few studies (n = 2) were at low risk of bias. In pooled analysis of case-control studies, ever use of marijuana was not associated with head and neck squamous cell carcinoma or oral cancer. In pooled analysis of 3 case-control studies, more than 10 years of marijuana use (joint-years not reported) was associated with TGCT (OR, 1.36; 95% CI, 1.03-1.81; P = .03; I2 = 0%) and nonseminoma TGCT (OR, 1.85; 95% CI, 1.10-3.11; P = .04; I2 = 0%). Evaluations of ever use generally found no association with cancers, but exposure levels were low and poorly defined. Findings for lung cancer were mixed, confounded by few marijuana-only smokers, poor exposure assessment, and inadequate adjustment; meta-analysis was not performed for several outcomes.

Conclusions and Relevance

Low-strength evidence suggests that smoking marijuana is associated with developing TGCT; its association with other cancers and the consequences of higher levels of use are unclear. Long-term studies in marijuana-only smokers would improve understanding of marijuana's association with lung, oral, and other cancers.

Trial Registration

PROSPERO identifier: CRD42018102457.

Menstrual Cycle in Women Who Co-use Marijuana and Tobacco

OBJECTIVE

Marijuana is the most commonly used illicit drug in the United States and co-use with tobacco is increasing. Preliminary studies have indicated that marijuana may suppress luteinizing hormone (LH) or shorten the luteal phase. Although the literature is mixed, these sex hormones may play a role in smoking cessation outcomes. This secondary subgroup analysis aims to explore the menstrual cycle of females who co-use marijuana and tobacco compared with females who only use tobacco in a sample of tobacco treatment-seeking individuals.

METHODS

Female participants, aged 18 to 50 years, who self-reported regular menstrual cycles and co-use of marijuana and tobacco were matched 1:3 by age to participants who only use tobacco. Length of the follicular and luteal phases was determined using First Response Urine LH tests. Wilcoxon 2-sample t tests were used to determine differences in phase lengths between groups.

RESULTS

Thirteen women who co-use marijuana and tobacco, and 39 women who only use tobacco were included in this analysis. Overall, participants were 37.3 ± 8.0 (SD) years of age, mostly Caucasian (67%), and smoked 12.6 ± 5.2 (SD) cigarettes per day. The luteal phase length among participants who co-use marijuana and tobacco (11.4 days ± 2.2 [SD]) was significantly shorter than among participants who only use tobacco (16.8 days ± 11.3 [SD]; P = 0.002). No differences were found in follicular phase length or menstrual cycle length.

CONCLUSIONS

These data suggest that females who co-use marijuana and tobacco may have a shortened luteal phase in comparison with females who only use tobacco. Further studies are needed to better understand how marijuana use may impact the menstrual cycle and affect smoking outcomes.

Increasing Depression and Substance Use Among Former Smokers in the United States, 2002-2016

INTRODUCTION

Mental health and substance use problems are associated with smoking relapse among former smokers. Yet, little is known about the prevalence of mental health and substance use among former smokers in the U.S. In addition, it is unknown whether the prevalence of these conditions has changed over time as former U.S. smokers have grown to outnumber current U.S. smokers. This study, which was conducted in 2018 and 2019, examined the prevalence and trends over time in depression (2005-2016), marijuana use (2002-2016), and alcohol use problems (2002-2016) among former U.S. smokers.

METHODS

The National Survey on Drug Use and Health is an annual, nationally representative, cross-sectional study. Data from U.S. individuals who were aged ≥18 years in 2002-2016 were included. Former smokers were defined as having smoked ≥100 lifetime cigarettes and no past-year cigarettes.

RESULTS

From 2005 to 2016, the prevalence of major depression increased from 4.88% to 6.04% (AOR=1.01, 95% CI=1.00, 1.03, p=0.04). From 2002 to 2016, past-year marijuana use rose from 5.35% to 10.09% (AOR=1.08, 95% CI=1.07, 1.09, p<0.001) among former smokers. Past-month binge alcohol use also increased from 17.22% to 22.33% (AOR=1.03, 95% CI=1.02, 1.04, p<0.001), although the prevalence of past-year alcohol abuse or dependence did not change.

CONCLUSIONS

Depression and substance use, which are factors associated with increased risk for cigarette use relapse, appear to be increasing over time among former U.S. smokers. Increased awareness of these trends may be important for clinical and public health efforts to direct attention to conditions potentially threatening sustained abstinence among former smokers.

Time Trends in the Co-use of Cannabis and the Misuse of Tranquilizers, Sedatives and Sleeping Pills among Young Adults in Spain between 2009 and 2015

The aims of this study were: (a) to estimate time trends in the prevalence of the co-use of cannabis and other cannabis-based products (CBP) with the misuse of tranquilizers, sedatives, and sleeping pills (TSSp) between 2009 and 2015; and (b) to identify the factors associated with the probability of the co-use of CBP with TSSp misuse during this period among Spanish younger adults (15–34 years old). We analyzed data collected from the Spanish National Surveys on Alcohol and Other Drugs (EDADES) in 2009, 2011, 2013, and 2015. CBP co-use with TSSp misuse were the dependent variables. We also analyzed sociodemographic features, self-perceived health status, lifestyle habits, perceived health risk of consumption, and perceived availability of substance using logistic regression models. The prevalence of CBP co-use with TSSp misuse has decreased in Spain. The factors associated with co-use were a lack of education (OR 2.34), alcohol (OR 7.2), tobacco (OR 6.3) and other illicit psychoactive drug (OR 6.5) consumption, perceived non-health risk for the consumption of CBP and TSSp (OR 3.27), and perceived availability of CBP (OR 2.96). Our study identified several factors that appear to affect CBP and TSSp co-use in younger adults, with potential implications for healthcare providers.

A National Survey of Marijuana Use Among US Adults With Medical Conditions, 2016-2017

IMPORTANCE

The number of states legalizing marijuana for medical and recreational use is increasing. Little is known regarding how or why adults with medical conditions use it.

OBJECTIVES

To report the prevalence and patterns of marijuana use among adults with and without medical conditions, overall and by sociodemographic group, and to further examine the associations between current marijuana use and the types and number of medical conditions.

DESIGN, SETTING, AND PARTICIPANTS

This survey study used a probability sample of US adults aged 18 years and older from the 2016 and 2017 Behavioral Risk Factor Surveillance System, a telephone-administered survey that collects data from a representative sample of US adult residents across the states regarding health-related risk behaviors, chronic health conditions, and use of preventive services.

MAIN OUTCOMES AND MEASURES

Current (past month) and daily (≥20 days in the last 30 days) marijuana use.

RESULTS

The study sample included 169 036 participants (95 780 female [weighted percentage, 52.0%]). Adults with medical conditions had higher odds of reporting current marijuana use than those without medical conditions (age 18-34 years: adjusted odds ratio, 1.8 [95% CI, 1.5-2.1]; age 35-54 years: adjusted odds ratio, 1.4 [95% CI, 1.2-1.7]; age ≥55 years: adjusted odds ratio, 1.6 [95% CI, 1.3-2.0]), especially among those with asthma, chronic obstructive pulmonary disease, arthritis, cancer, and depression. Among those with medical conditions, the prevalence of marijuana use decreased with increasing age, ranging from 25.2% (95% CI, 22.0%-28.3%) for those aged 18 to 24 years to 2.4% (95% CI, 2.0%-2.8%) for those aged 65 years or older for current marijuana use and from 11.2% (95% CI, 8.7%-13.6%) to 0.9% (95% CI, 0.7%-1.2%), respectively, for daily marijuana use. Most adults who used marijuana (77.5%; 95% CI, 74.7%-80.3%), either with or without medical conditions, reported smoking as their primary method of administration. Adults with medical conditions were more likely than those without medical conditions to report using marijuana for medical reasons (45.5% [95% CI, 41.1%-49.8%] vs 21.8% [95% CI, 17.8%-25.7%]; difference, 23.7% [95% CI, 17.8%-29.6%]) and less likely to report using marijuana for recreational purposes (36.2% [95% CI, 32.1%-40.3%] vs 57.7% [95% CI, 52.6%-62.9%]; difference, -21.5% [95% CI, -28.1% to 14.9%]).

CONCLUSIONS AND RELEVANCE

This study found that marijuana use was more common among adults with medical conditions than those without such conditions. Notably, 11.2% of young adults with medical conditions reported using marijuana on a daily basis. Clinicians should screen for marijuana use among patients, understand why and how patients are using marijuana, and work with patients to optimize outcomes and reduce marijuana-associated risks.

Microbiomic differences at cancer-prone oral mucosa sites with marijuana usage

Marijuana smoke contains cannabinoids, immunosuppressants, and a mixture of potentially-mutagenic chemicals. In addition to systemic disease, it is thought to contribute to oral disease, such as tooth loss, tissue changes in the gums and throat, and possibly oral pharyngeal cancer. We used a cross-sectional study of 20 marijuana users and 19 control non-users, to determine if chronic inhalation-based exposure to marijuana was associated with a distinct oral microbiota at the two most common sites of head and neck squamous cell carcinoma (HNSCC), the lateral border of the tongue and the oral pharynx. At the tongue site, genera earlier shown to be enriched on HNSCC mucosa, Capnocytophaga, Fusobacterium, and Porphyromonas, were at low levels in marijuana users, while Rothia, which is found at depressed levels on HNSCC mucosa, was high. At the oral pharynx site, differences in bacteria were distinct, with higher levels of Selenomonas and lower levels of Streptococcus which is what is seen in HNSCC. No evidence was seen for a contribution of marijuana product contaminating bacteria to these differences. This study revealed differences in the surface oral mucosal microbiota with frequent smoking of marijuana.

Using wastewater-based analysis to monitor the effects of legalized retail sales on cannabis consumption in Washington State, USA

AIMS

To perform a wastewater-based analysis to explore the impact of newly legalized retail cannabis sales on its use and to determine if this approach could estimate the size of the legal market place, which began 1 August 2014 in the study area.

DESIGN

Laboratory study of raw wastewater samples collected and analyzed over the 3-year period from 2014 to 2016.

SETTING AND PARTICIPANTS

Samples obtained from the two wastewater treatment plants that serviced a municipality of 200 000 people in the state of Washington, USA.

MEASUREMENTS

Quantitative analysis of 24-hour composite influent samples for the metabolite of the active ingredient in cannabis, 11-nor-9-Carboxy-Δ9-tetrahydrocannabinol (THC-COOH) were performed by liquid chromatography coupled to mass spectrometry.

FINDINGS

Wastewater estimates for THC-COOH increased by 9% per quarter, suggesting a doubling in cannabis consumption from 1 December 2013 to 31 December 2016. State-sold THC increased at nearly 70% per quarter, while stores operated from 1 August 2014 to 31 December 2016. Estimating the proportion of the total cannabis market supplied by state-regulated cannabis from these data is not currently achievable.

CONCLUSION

A wastewater-based measure of cannabis consumption suggests a significant increase in consumption in Washington, USA following legalization, and that legal sales appear to have displaced a large portion of the illicit market.

Effects in rats of adolescent exposure to cannabis smoke or THC on emotional behavior and cognitive function in adulthood

RATIONALE

Cannabis use is common among adolescents and some research suggests that adolescent cannabis use increases the risk for depression, anxiety, and cognitive impairments in adulthood. In human studies, however, confounds may affect the association between cannabis use and the development of brain disorders.

OBJECTIVES

These experiments investigated the effects of adolescent exposure to either cannabis smoke or THC on anxiety- and depressive-like behavior and cognitive performance in adulthood in Long-Evans rats.

METHODS

Adolescent rats of both sexes were exposed to either cannabis smoke from postnatal days (P) 29-49 or ascending doses of THC from P35-45. When the rats reached adulthood (P70), anxiety-like behavior was investigated in the large open field and elevated plus maze, depressive-like behavior in the sucrose preference and forced swim tests, and cognitive function in the novel object recognition test.

RESULTS

Despite sex differences on some measures in the open field, elevated plus maze, forced swim, and novel object recognition tests, there were no effects of either adolescent cannabis smoke or THC exposure, and only relatively subtle interactions between exposure conditions and sex, such that sex differences on some performance measures were slightly attenuated.

CONCLUSION

Neither cannabis smoke nor THC exposure during adolescence produced robust alterations in adult behavior after a period of abstinence, suggesting that adverse effects associated with adolescent cannabis use might be due to non-cannabinoid concomitants of cannabis use.

Frontal Alpha Asymmetry and Inhibitory Control among Individuals with Cannabis Use Disorders

To better understand the biopsychosocial mechanisms associated with development and maintenance of cannabis use disorder (CUD), we examined frontal alpha asymmetry (FAA) as a measure of approach bias and inhibitory control in cannabis users versus healthy nonusers. We investigated: (1) whether FAA could distinguish cannabis users from healthy controls; (2) whether there are cue-specific FAA effects in cannabis users versus controls; and (3) the time course of cue-specific approach motivation and inhibitory control processes. EEG data were analyzed from forty participants (CUD (n = 20) and controls (n = 20)) who completed a modified visual attention task. Results showed controls exhibited greater relative right hemisphere activation (indicating avoidance/withdrawal motivation) when exposed to cannabis cues during the filtering task. By contrast, cannabis users exhibited greater relative left activation (approach) to all cues (cannabis, positive, negative, and neutral), reflecting a generalized approach motivational tendency, particularly during later stages of inhibitory control processes. The difference between cannabis users and controls in FAA was largest during mid- to late processing stages of all cues, indicating greater approach motivation during later stages of information processing among cannabis users. Findings suggest FAA may distinguish cannabis users from healthy controls and shows promise as a measure of inhibitory control processes in cannabis users.

Burden of Comorbidities in Hospitalizations for Cannabis Use-associated Intractable Vomiting during Post-legalization Period

Objective The aim of this study was to observe the trends of intractable vomiting and cannabis use disorder (CUD) with demographic characteristics, medical and psychiatric comorbidities, and hospitalization outcomes. Methods We conducted a retrospective cohort study using the nationwide inpatient sample (2010 to 2014). Patients aged 16-50 years discharged with a primary diagnosis of intractable vomiting and CUD were included (N = 9,601). We used the linear-by-linear association chi-square test and independent-sample T-test for measuring the categorical and continuous data, respectively. Results The number of intractable vomiting hospitalizations with CUD had an increasing trend (P < 0.001) with a 28.6% increase over five years. About half of the study population included young (16-30 years, 48.4%) males (57.2%). There was a decreasing trend (P = 0.041) in the prevalence of intractable vomiting with CUD in non-Hispanic Whites and Blacks, whereas there was 778% increase in Hispanics. The mean length of stay was 3.2 days which had a decreasing linear trend, and total hospital charges showed an increasing trend (P < 0.001), averaging $22,890. Electrolyte disorders (55.3%), hypertension (25.3%), chronic lung disease (11.9%), and deficiency anemia (10.3%) constituted the majority of comorbidities, with anemia showing a statistically significant increasing trend (P = 0.004). Anxiety disorders increased from 20.8% to 30.8% over five years, whereas depression decreased from 19.2% to 16.4% (P < 0.001). Concomitant tobacco abuse/dependence was present in 41.2% of patients with CUD. Conclusion The results of our study show that the intractable vomiting hospitalizations related to CUD have increased significantly over a five-year period. The general public and healthcare practitioners should be made aware of the paradoxical gastrointestinal side effects of cannabis.

Cannabis use is associated with potentially heritable widespread changes in autism candidate gene DLGAP2 DNA methylation in sperm

Parental cannabis use has been associated with adverse neurodevelopmental outcomes in offspring, but how such phenotypes are transmitted is largely unknown. Using reduced representation bisulphite sequencing (RRBS), we recently demonstrated that cannabis use is associated with widespread DNA methylation changes in human and rat sperm. Discs-Large Associated Protein 2 (DLGAP2), involved in synapse organization, neuronal signaling, and strongly implicated in autism, exhibited significant hypomethylation (p < 0.05) at 17 CpG sites in human sperm. We successfully validated the differential methylation present in DLGAP2 for nine CpG sites located in intron seven (p < 0.05) using quantitative bisulphite pyrosequencing. Intron 7 DNA methylation and DLGAP2 expression in human conceptal brain tissue were inversely correlated (p < 0.01). Adult male rats exposed to delta-9-tetrahydrocannabinol (THC) showed differential DNA methylation at Dlgap2 in sperm (p < 0.03), as did the nucleus accumbens of rats whose fathers were exposed to THC prior to conception (p < 0.05). Altogether, these results warrant further investigation into the effects of preconception cannabis use in males and the potential effects on subsequent generations.

Association between cannabis laws and opioid prescriptions among privately insured adults in the US

We examine the association between opioid prescription patterns in privately insured adults and changes in state cannabis laws among five age groups (18-25, 26-35 36-45, 46-55 and 56-64 years). Using the 2016 Clinformatics Data Mart, a nationwide commercial health insurance database, we performed a cross-sectional analysis of two types of opioid prescribing (>30-day and >90-day prescriptions) among all adults aged 18-64 based on the stringency of cannabis laws. We found a significant interaction between age and cannabis law on opioid prescriptions. Age-stratified multilevel multivariable analyses showed lower opioid prescription rates in the four younger age groups only in states with medical cannabis laws, when considering both >30 day and >90 day opioid use [>30 day adjusted odds ratio (aOR) = 0.56, in 18-25, aOR = 0.67 in 26-35, aOR = 0.67 in 36-45, and aOR = 0.76 in 46-54 years; >90 day aOR = 0.56, in 18-25, aOR = 0.68 in 26-35, aOR = 0.69 in 36-45, and aOR = 0.77 in 46-54 years, P < 0.0001 for all]. This association was not significant in the oldest age group of 55-64 years. There was no significant association between opioid prescriptions and other categories of cannabis laws (recreational use and decriminalization) in any of the age groups studied.

Investigating how perceived risk and availability of marijuana relate to marijuana use among adolescents in Argentina, Chile, and Uruguay over time

AIMS

Amid changing marijuana policies in the Southern Cone, we examined relationships between marijuana-related risk factors and marijuana use among adolescents in Argentina, Chile, and Uruguay from 2001 to 2016.

METHODS

Using cross-sectional surveys from 8^th, 10^th, and 12^th graders and weighted time-varying effect models, we estimated associations between perceived risk (no/low risk versus moderate/great risk) and perceived availability (easy/very easy versus difficult/very difficult/not able to obtain) of marijuana, and any past-month marijuana use.

RESULTS

In all countries, marijuana use increased over time and adolescents who perceived no/low risk and easy availability had higher odds of use. In Argentina, the bivariate risk/use association weakened from 2001 (OR = 15.24, 95%CI = 9.63, 24.12) to 2004 [OR = 3.86 (2.72, 5.48)] and strengthened until 2011 [OR = 8.22 (7.56, 10.30)]; the availability/use association strengthened from 2005 [OR = 5.32 (4.05, 6.98)] to 2009 [OR = 20.77 (15.57, 27.70)] and weakened until 2014 [OR = 11.00 (9.11, 13.27)]. In Chile, the risk/use association weakened from 2001 [OR = 7.22 (6.57, 7.95)] to 2015 [OR = 5.58 (4.82, 6.48)]; the availability/use association weakened from 2001 [OR = 5.92 (4.96, 7.06)] to 2015 [OR = 4.10 (3.15, 5.34)]. In Uruguay, the risk/use association weakened from 2003 [OR = 34.22 (22.76, 51.46)] to 2016 [OR = 6.23 (4.96, 7.83)]; the availability/use association weakened from 2005 [OR = 29.13 (13.39, 63.39) to 2007 [OR = 9.42 (3.85, 23.07)], and strengthened until 2016 [OR = 22.68 (12.03, 42.76)].

CONCLUSIONS

Overall, the association between risk and use weakened in all countries, suggesting risk perceptions became a weaker determinant of marijuana use. Perceived availability remained strongly associated with use and may become an increasingly important driver of use (particularly in Uruguay and Argentina).

Subgroup trends in alcohol and cannabis co-use and related harms during the rollout of recreational cannabis legalization in Washington state

BACKGROUND

The US state of Washington legalized recreational cannabis in 2012; how this impacted the co-use of cannabis and alcohol in the population overall and among key subgroups has not been examined. The aim of this study is to investigate changes in patterns of alcohol- and cannabis use and alcohol-related harms during the rollout of retail recreational cannabis stores.

METHODS

Data come from six cross-sectional samples recruited between January 2014-October 2016 via Random Digit Dial procedures (N = 5492). Survey-weighted multivariable regression adjusting for gender, age, race/ethnicity, education, employment, marital status, cannabis use, and survey year were used for statistical analyses.

RESULTS

In the sample overall, no significant changes were observed in any alcohol use measures between 2014-2016, while the prevalence of cannabis use significantly (P < 0.05) increased from 25.0% to 31.7%, the prevalence of alcohol-related harms at home significantly decreased from 2.1% to 1.0%, and the prevalence of alcohol-related financial harms decreased from 1.5% to 0.8%. Both women and men significantly increased any cannabis use, while women also experienced significantly fewer alcohol-related harms at home and financial harms over time, and increases in the prevalence of cannabis users/non-drinkers. Those 18-29 years old significantly reduced the number of drinking days and overall volume in the past 30 days, and those 30-49 years old significantly decreased alcohol-related harms at home and financial harms. Those 50+ years old significantly increased any cannabis use and simultaneous use of cannabis and alcohol. Non-cannabis users slightly decreased average number of drinks/day, and cannabis users significantly decreased alcohol-related financial harms.

CONCLUSIONS

Between 2014-2016, the years during and immediately following the introduction of legal recreational cannabis stores in Washington state, there were no significant changes in cannabis and alcohol co-use or overall alcohol consumption. The only significant changes in the sample overall were an increase in any cannabis use and decreases in alcohol-related harms at home and alcohol-related financial harms.

Cannabis-Associated Asthma and Allergies

Inhalation of cannabis smoke is its most common use and the pulmonary complications of its use may be the single most common form of drug-induced pulmonary disease worldwide. However, the role of cannabis consumption in asthma patients and allergic clinical situations still remains controversial. To review the evidence of asthma and allergic diseases associated with the use of marijuana, we conducted a search of English, Spanish, and Portuguese medical using the search terms asthma, allergy, marijuana, marihuana, and cannabis. Entries made between January 1970 and March 2017 were retrieved. Several papers have shown the relationship between marijuana use and increase in asthma and other allergic diseases symptoms, as well as the increased frequency of medical visits. This narrative review emphasizes the importance to consider cannabis as a precipitating factor for acute asthma and allergic attacks in clinical practice. Although smoking of marijuana may cause respiratory symptoms, there is a need for more studies to elucidate many aspects in allergic asthma patients, especially considering the long-term use of the drug. These patients should avoid using marijuana and be oriented about individual health risks, possible dangers of second-hand smoke exposure, underage use, safe storage, and the over smoking of marijuana.

Does liberalisation of cannabis policy influence levels of use in adolescents and young adults? A systematic review and meta-analysis

OBJECTIVES

To examine the effect of cannabis policy liberalisation (decriminalisation and legalisation) levels of use in adolescents and young adults.

DESIGN

Systematic review and meta-analysis.

INCLUSION CRITERIA

Included studies were conducted among individuals younger than 25 years and quantitatively assessing consequences of cannabis policy change. We excluded articles: (A) exclusively based on participants older than 25 years; (B) only reporting changes in perceptions of cannabis use; (C) not including at least two measures of cannabis use; (D) not including quantitative data; and (E) reviews, letters, opinions and policy papers. PubMed, PsycINFO, Embase and Web of Science were searched through 1 March 2018.

DATA EXTRACTION AND SYNTHESIS

Two independent readers reviewed the eligibility of titles and abstracts and read eligible articles, and four authors assessed the risk of bias (Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies). Extracted data were meta-analysed. The protocol was registered with PROSPERO.

RESULTS

3438 records were identified via search terms and four via citation lists; 2312 were retained after removal of duplicates, 99 were assessed for eligibility and 41 were included in our systematic review. 13 articles examined cannabis decriminalisation, 20 examined legalisation for medical purposes and 8 examined legalisation for recreational purposes. Findings regarding the consequences of cannabis decriminalisation or legalisation for medical purposes were too heterogeneous to be meta-analysed. Our systematic review and meta-analysis suggest a small increase in cannabis use among adolescents and young adults following legalisation of cannabis for recreational purposes (standardised mean difference of 0.03, 95% CI -0.01 to -0.07). Nevertheless, studies characterised by a very low/low risk of bias showed no evidence of changes in cannabis use following policy modifications.

CONCLUSIONS

Cannabis policy liberalisation does not appear to result in significant changes in youths' use, with the possible exception of legalisation for recreational purposes that requires monitoring.

TRIAL REGISTRATION NUMBER

CRD42018083950.

Self-reported Daily, Weekly, and Monthly Cannabis Use Among Women Before and During Pregnancy

IMPORTANCE

As the overall prevalence of prenatal cannabis use rises, it is vital to also monitor trends in the frequency of cannabis use in the period leading up to and during pregnancy because more frequent use may confer greater health risks for mothers and their children.

OBJECTIVE

To examine trends in the frequency of self-reported cannabis use among pregnant women in the year before and during pregnancy.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study using data from 367 403 pregnancies among 276 991 women 11 years or older who completed a self-administered questionnaire on cannabis use during standard prenatal care in Kaiser Permanente Northern California from January 1, 2009, to December 31, 2017. The annual prevalence of self-reported daily, weekly, and monthly cannabis use among women before and during pregnancy was estimated using Poisson regression with a log link function, adjusting for sociodemographics. Data analyses were conducted from February to May 2019.

EXPOSURES

Calendar year.

MAIN OUTCOMES AND MEASURES

Self-reported frequency of cannabis use in the year before pregnancy and during pregnancy assessed as part of standard prenatal care (at approximately 8 weeks' gestation).

RESULTS

Among the overall sample of 367 403 pregnancies among 276 991 women, 35.9% of the women self-reported white race/ethnicity; 28.0%, Hispanic; 16.6%, Asian; 6.0%, African American; and 13.5%, other. In the sample, 1.2% of the women were aged 11 to 17 years; 15.3%, 18 to 24 years; 61.4%, 25 to 34 years; and 22.0%, older than 34 years. Median (interquartile range) neighborhood household income was $70 472 ($51 583-$92 643). From 2009 to 2017, the adjusted prevalence of cannabis use in the year before pregnancy increased from 6.80% (95% CI, 6.42%-7.18%) to 12.50% (95% CI, 12.01%-12.99%), and the adjusted prevalence of cannabis use during pregnancy increased from 1.95% (95% CI, 1.78%-2.13%) to 3.38% (95% CI, 3.15%-3.60%). Annual relative rates of change in self-reported daily cannabis use (1.115; 95% CI, 1.103-1.128), weekly cannabis use (1.083; 95% CI, 1.071-1.095), and monthly or less cannabis use (1.050; 95% CI, 1.043-1.057) in the year before pregnancy increased significantly, with daily use increasing most rapidly (from 1.17% to 3.05%). Similarly, annual relative rates of change in self-reported daily cannabis use (1.110; 95% CI, 1.089-1.132), weekly cannabis use (1.075; 95% CI, 1.059-1.092) and monthly or less cannabis use (1.044; 95% CI, 1.032-1.057) during pregnancy increased significantly from 2009 to 2017, with daily use increasing most rapidly (from 0.28% to 0.69%).

CONCLUSIONS AND RELEVANCE

Results of this study demonstrate that frequency of cannabis use in the year before pregnancy and during pregnancy has increased in recent years among pregnant women in Northern California, potentially associated with increasing acceptance of cannabis use and decreasing perceptions of cannabis-associated harms.

Is Cannabis Use Associated With Increased Risk of Cigarette Smoking Initiation, Persistence, and Relapse? Longitudinal Data From a Representative Sample of US Adults

OBJECTIVE

The current study prospectively investigated the relationship between cannabis use and cigarette smoking initiation, persistence, and relapse during a 3-year period among adults in the United States.

METHODS

Analyses included respondents who completed Waves 1 (2001-2002) and 2 (2004-2005) of the National Epidemiologic Survey on Alcohol and Related Conditions and responded to questions about cannabis use and smoking status (n = 34,639). Multivariable logistic regression models were used to calculate the odds of cigarette use at Wave 2 among Wave 1 daily smokers, nondaily smokers, former smokers, and nonsmokers by Wave 1 cannabis use.

RESULTS

In unadjusted analyses, Wave 1 cannabis use was associated with increased odds of Wave 2 daily and nondaily smoking for Wave 1 nonsmokers (daily OR = 2.90; 95% CI, 2.10-4.00; nondaily OR = 4.45; 95% CI, 3.97-5.00) and Wave 2 relapse to daily and nondaily smoking for Wave 1 former smokers (daily OR = 4.18, 95% CI, 3.01-5.81; nondaily OR = 5.24; 95% CI, 3.74-7.34). Wave 1 cannabis use was associated with decreased odds of Wave 2 smoking cessation for Wave 1 daily cigarette smokers (OR = 0.57; 95% CI, 0.51-0.64). The associations remained significant for daily smoking initiation (OR = 1.43; 95% CI, 1.06-1.93), daily smoking relapse (OR = 1.47; 95% CI, 1.00-2.16), and smoking cessation (OR = 0.77; 95% CI, 0.69-0.87) after adjusting for demographics and psychiatric disorders. Associations remained significant for nondaily smoking initiation (OR = 1.85; 95% CI, 1.59-2.16) and nondaily smoking relapse (OR = 1.63; 95% CI, 1.05-2.54) after adjusting for these covariates as well as for alcohol and substance use disorders.

CONCLUSIONS

Cannabis use was associated with increased initiation of, persistence of, and relapse to cigarette smoking. Additional attention to cannabis use in tobacco control efforts and in clinical settings aimed at reducing cigarette smoking and smoking-related negative consequences may be warranted.

Cannabis use, problem-gambling severity, and psychiatric disorders: Data from the National Epidemiological Survey on Alcohol and Related Conditions

Cannabis use and related disorders are common in adults and frequently co-occur with subsyndromal and pathological gambling. However, understanding how cannabis use may moderate relationships between problem-gambling severity and psychiatric disorders remains poorly understood. Data from the National Epidemiological Survey on Alcohol and Related Conditions (N = 43,093 adults) were examined to investigate how cannabis use moderated associations between problem-gambling severity (with gambling groups based on the 10 Diagnostic and Statistical Manual [DSM-IV] inclusionary criteria for pathological gambling) and Axis I and Axis II psychiatric disorders. Problem-gambling severity groups included low frequency/nongambling, low-risk gambling, at-risk gambling, and problem/pathological gambling (PPG). Among both the group with lifetime cannabis use and that which never used cannabis, greater problem-gambling severity was associated with more psychopathology across mood, anxiety, substance-use and Axis II disorders. Significant Cannabis Use × Problem-Gambling Severity Group interactions were observed between PPG and major depression (OR = 0.35, 95% CI = [0.14-0.85]), cluster A personality disorders (OR = 0.37, 95% CI = [0.16-0.86])-especially paranoid personality disorder (OR = 0.34, 95% CI = [0.14-0.81])-and cluster B personality disorders (OR = 0.36, 95% CI = [0.18-0.75])-especially antisocial personality disorder (OR = 0.25, 95% CI = [0.11-0.60]). In all cases, associations between problem-gambling severity and psychopathologies were weaker among the lifetime-cannabis-using group as compared to the never-using group. Cannabis use moderates the relationships between problem-gambling severity and psychiatric disorders, with cannabis use appearing to account for some of the variance in the associations between greater problem-gambling severity and specific forms of psychopathology. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Perceived Risk of Heroin in Relation to Other Drug Use in a Representative US Sample

Low perception of risk is a risk factor for heroin use. Research is needed to determine whether this risk factor for heroin use is affected by the use of other drugs. Data were analyzed from participants in the 2015/2016 National Surveys on Drug Use and Health who denied lifetime heroin use (N= 110,102). We examined how recency of use of various drugs and number of drugs used relate to perceptions that using heroin is not a great risk. Results from multivariable models suggest that no lifetime drug use, and recent prescription opioid misuse and methamphetamine use, in particular, were associated with higher odds of perceiving that heroin use is not of great risk. Recent marijuana use was associated with lower odds of reporting that heroin use is not of great risk. Use of more drugs in one's lifetime, past year, and/or past month tended to be associated with lower odds of reporting heroin use as not a great risk. Prevention experts should consider that recent prescription opioid misuse in particular is a risk factor for the lower perception of risk, while individuals reporting no lifetime drug use may also require better education regarding harms associated with heroin use.

Density of Medical Marijuana Dispensaries and Current Marijuana Use among Young Adult Marijuana Users in Los Angeles

Background: While tobacco and alcohol studies have focused on density of outlets as a determinant of consumption, research has begun examining the effects of medical marijuana (MM) dispensaries on marijuana use. Objectives: Examine the relationship between density of MM dispensaries and frequency of marijuana use among young adult medical marijuana patients (MMP) and nonpatient users (NPU). Methods: Young adult marijuana users (n = 329) aged 18- to 26-year old were sampled in Los Angeles in 2014-2015 and separated into MMP (n = 198) and NPU (n = 131). In 2014, 425 operational MM dispensaries were identified within the City of Los Angeles. Sequential multilevel Poisson random effect models examined density of MM dispensaries per square mile and 90 d marijuana use among MMP and NUP at the ZIP code level while controlling for demographic, behavioral, and community characteristics. Results: Density of MM dispensaries was not related to 90 d use of marijuana (days of use or hits per day) among either MMP or NPU. MMP reported significantly greater days of marijuana use in the past 90 d compared to NPU but no differences were found for hits per day. African-Americans reported significantly greater hits per day compared to whites. Hispanics reported significantly fewer hits per day compared to non-Hispanics. Conclusion: Concentration of MM dispensaries surrounding young adult marijuana users in Los Angeles was unrelated to days of marijuana use irrespective of having a MM recommendation or not. Rather, individual factors related to consumer choices and behaviors were more important in determining recent marijuana use among MMP and NPU.

Marijuana-induced Coronary Vasospasm with Persistent Inter-coronary Connection: A Case Report and Review of Literature

Coronary vasospasm is a well-known entity causing acute chest syndrome and can lead to myocardial infarction, ventricular arrhythmias, and even sudden cardiac death. While there are extensive case series showing the association of coronary vasospasm with cocaine, studies reporting marijuana-induced coronary vasospasm are limited in number. We herein present a case of coronary vasospasm in a middle-aged African-American male who presented to the emergency department after an episode of syncope. His urine drug screen was positive only for marijuana. He had a transient elevation of ST segments on his EKG with concomitant wall motion abnormalities on echocardiogram and was later found to have vasospasm of coronary arteries on coronary angiogram without any evidence of focal atherosclerotic disease. Another interesting finding was the persistent inter-coronary communication or coronary arcade connecting the left circumflex artery to the right coronary artery. There was bi-directional flow through the inter-coronary communication and hence, we believe this communication prevented our patient from experiencing acute chest symptoms or myocardial infarction. It is important for the clinicians to recognize the association of marijuana with coronary vasospasm. At the same time, these patients should be treated as acute coronary syndromes until proven otherwise by ischemia evaluation.

Types of cannabis and tobacco/nicotine co-use and associated outcomes in young adulthood

Cannabis and tobacco/nicotine use are highly comorbid. Given expanding access to cannabis through legalization for recreational use, it is important to understand how patterns of cannabis and tobacco/nicotine co-use are associated with young adult outcomes. A predominantly California-based sample of 2,429 young adults (mean age = 20.7) completed an online survey. Based on past-year reports of cannabis and tobacco/nicotine use, we defined 5 mutually exclusive groups: (a) single-product use; (b) concurrent use only (using both products, but only on separate occasions); (c) sequential use only (using both products on the same occasion, one right after the other, but not mixing them together); (d) coadministration only (using both products on the same occasion by mixing them in the same delivery device); and (e) both sequential use and coadministration. We examined group differences in use patterns, dependence, consequences of use, and psychosocial functioning. Fifty percent of respondents reported cannabis use, 43% tobacco/nicotine use, and 37% co-use of both substances. The most prevalent method of co-use involved smoking combustible products. Overall, individuals who co-used both substances on the same occasion in some way reported heavier use and greater problematic behaviors than those who did not. Sequential use (especially among those that also engaged in coadministration) was typically associated with worse physical and mental functioning overall compared to using each substance separately. Findings illuminate both prevalence and risks associated with co-use of cannabis and tobacco/nicotine products and can inform policies for states considering regulation of cannabis and tobacco/nicotine products. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Cannabis and Tramadol are Prevalent among the First Episode Drug-Induced Psychosis in the Egyptian Population: Single Center Experience

(1) Background: Cannabis and tramadol are featuring prominently in Egypt; however, their prevalence in first episode psychosis is still uncertain. We aimed at determining the prevalence of cannabis and tramadol among the first-psychotic episode in Egyptian inpatients and to compare the demographic and psychopathological profiles of substance abusers versus patients with the comorbid diagnosis. (2) Methods: Patients presented with psychotic episode and admitted to Mansoura Psychiatric Department were recruited. Diagnosis of psychiatric illness and drug/substance use was carried out using the Diagnostic and Statistical Manual- Fourth Edition (DSM-IV) criteria. Standard urine tests and thin layer chromatography were performed to detect cannabis and tramadol. (3) Results: Of the 100 subjects in the study, the majority (55.6%) of patients were cannabis-only positive. Overall, cannabis-alone showed the highest frequency of substance used among the currently diagnosed psychotic disorders. According to urine tests, cannabis demonstrates the higher frequency of intake in both studied groups. 66.7% of the studied population had 1–5 years self-reported histories of substance abuse predating the first psychotic episode. (4) Conclusions: The percentage of cannabis and tramadol among the first episode psychotic patients has been unexpectedly high and the standard urine testing should be considered in emergency and mental health facilities.

Prenatal cannabinoid exposure and altered neurotransmission

Marijuana is one of the most commonly used illicit drugs worldwide. In addition, use of synthetic cannabinoids is increasing, especially among adolescents and young adults. Although human studies have shown that the use of marijuana during pregnancy leads to adverse behavioral effects, such as deficiencies in attention and executive function in affected offspring, the rate of marijuana use among pregnant women is steadily increasing. Various aspects of human behavior including emotion, learning, and memory are dependent on complex interactions between multiple neurotransmitter systems that are especially vulnerable to alterations during the developmental period. Thus, exploration of neurotransmitter changes in response to prenatal cannabinoid exposure is crucial to develop an understanding of how homeostatic imbalance and various long-term neurobehavioral deficits manifest following the abuse of marijuana or other synthetic cannabinoids during pregnancy. Current literature confirms that vast alterations to neurotransmitter systems are present following prenatal cannabinoid exposure, and many of these alterations within the brain are region specific, time-dependent, and sexually dimorphic. In this review, we aim to provide a summary of observed changes to various neurotransmitter systems following cannabinoid exposure during pregnancy and to draw possible correlations to reported behavioral alterations in affected offspring.

Unilateral cilioretinal artery occlusion following cannabis use

There is a growing trend towards the decriminalization of cannabis and this is associated with its increased use over the past decade. Although a variety of adverse effects are attributed to its use, complications involving the eye are rare. We present the case of cilioretinal artery occlusion in a young man with no previous medical history. We discuss the management offered to him and present a review of the literature on this topic. Given the cilioretinal artery occlusion, medical management achieved an excellent result, with his best-corrected visual acuity improving to 6/12. Cilioretinal artery occlusions in healthy young individuals are extremely rare. The only risk factor identified in this patient was the use of cannabis on one occasion prior to his symptoms. There are no other cases in the literature that associate this complication with cannabis use and therefore it serves to raise awareness among the ophthalmic community.

Serious psychological distress and daily cannabis use, 2008 to 2016: Potential implications for mental health?

BACKGROUND

Daily cannabis use is increasing in the United States (US). Yet, it is not known whether daily cannabis use is disproportionately common, or whether it has increased differentially over time, by mental health status. This study estimated the prevalence of daily cannabis use among adults in the US with and without past-month serious psychological distress (SPD; measured by the Kessler Psychological Distress Scale (K6)) in 2016 and estimated trends in daily cannabis use by past-30-day SPD status from 2008 to 2016.

METHODS

Data were drawn from adults age 18 and older in the 2008-2016 National Survey on Drug Use and Health (combined total analytic sample n = 356,413). Linear time trends of daily cannabis use, stratified by SPD status, were assessed using logistic regression models with continuous year as the predictor.

RESULTS

In 2016, past-month daily cannabis use was significantly more common among those with past-month SPD (8.07%), compared to those without past-month SPD (2.66%). Daily cannabis use increased significantly from 2008 to 2016 among those both with and without SPD although use among those with SPD was persistently higher than use among those without SPD over the time period studied.

CONCLUSIONS

Daily cannabis use is significantly more common among persons with serious psychological distress and is increasing in this group, as well as among those without. Given this increase and the high prevalence of cannabis use among those with SPD, it may be important to consider potential consequences of this increased use for those with mental health vulnerabilities.

Changes over time in marijuana use, deviant behavior and preference for risky behavior among US adolescents from 2002 to 2014: testing the moderating effect of gender and age

BACKGROUND AND AIMS

Among adolescents, risk preference and deviant behaviors are associated with marijuana use, which exhibit substantial historical trends. We examined (1) trends, (2) effect modification by sex and age, (3) associations of marijuana use with deviant behaviors and risk preferences and (4) differences by sex, age and year.

DESIGN

Adjusted logistic and relative risk regression models, using data from the 2002-14 National Survey on Drug Use and Health, annual cross-sectional surveys of US households.

SETTING

United States.

PARTICIPANTS

A nationally representative sample of adolescents aged 12-17 years (n = 230 452).

MEASUREMENTS

We estimated associations between past-year marijuana use [self-reported using computer-assisted personal interviewing/audio computer-assisted self-interviewing (CAPI/ACASI)], deviant behavior (i.e. selling drugs; stealing; attacking someone) and risk preference (i.e. getting a kick; testing oneself).

FINDINGS

Marijuana use, deviant behaviors and risk preferences declined among adolescents from 2002 to 2014. There were no significant sex or age differences in the decline of marijuana use over time. There were sex [sold drugs: β = 0.90, 95% confidence interval (CI) = 0.75, 1.04] and age (attacked someone: β = 0.32, 95% CI = 0.22, 0.42) differences in the prevalence of deviant behaviors, and trends over time differed by sex and age for attacking someone.

CONCLUSIONS

While marijuana use, deviant behavior and risk preferences among US adolescents declined from 2002 to 2014, associations have remained stable, with marijuana use positively associated with deviant behaviors and risk preferences.

Associations of first trimester co-use of tobacco and Cannabis with prenatal immune response and psychosocial well-being

PURPOSE

This study aims to describe the association of first trimester co-use of tobacco and cannabis with maternal immune response and psychosocial well-being, relative to tobacco use only.

METHODS

A preliminary midpoint analysis included 138 pregnant women with biologically verified tobacco use, 38 of whom (28%) also tested positive for recent cannabis use. Maternal perceived stress (Perceived Stress Scale), depressive symptoms (Edinburgh Postnatal Depression Scale), and serum immune markers (IL-1β, IL-2, IL-6, IL-8, IL-10, TNFα, CRP, MMP8), were collected, although cytokine data were only available for 122 women.

RESULTS

Participant average age was 29.1 years, approximately half had a high school education or less, and half were unemployed. Compared to tobacco only users, co-users were more likely to be non-White, younger and more economically disadvantaged. In the adjusted linear regression models, TNF-α levels were significantly lower among co-users relative to tobacco only users, after adjusting for age, race/ethnicity, body mass index and tobacco use group (tobacco cigarettes, electronic nicotine delivery devices [ENDS] or both). TNF-α was the only immune marker found to be significant in this analysis. Measured stress levels (M = 5.9, SD = 3.3; potential range 0-16) and depression scores (M = 7.8, SD = 5.8; potential range 0-30) were low across all participants and did not differ as a function of co-use.

CONCLUSION

Preliminary results suggest women co-using during the first trimester exhibit decreased pro-inflammatory immune responsivity on one out of eight markers. Further research is needed to determine the impact of this immune modulation on fetal health outcomes and the unique contribution of cannabis.

Psychosis with Methylphenidate or Amphetamine in Patients with ADHD

BACKGROUND

The prescription use of the stimulants methylphenidate and amphetamine for the treatment of attention deficit-hyperactivity disorder (ADHD) has been increasing. In 2007, the Food and Drug Administration mandated changes to drug labels for stimulants on the basis of findings of new-onset psychosis. Whether the risk of psychosis in adolescents and young adults with ADHD differs among various stimulants has not been extensively studied.

METHODS

We used data from two commercial insurance claims databases to assess patients 13 to 25 years of age who had received a diagnosis of ADHD and who started taking methylphenidate or amphetamine between January 1, 2004, and September 30, 2015. The outcome was a new diagnosis of psychosis for which an antipsychotic medication was prescribed during the first 60 days after the date of the onset of psychosis. To estimate hazard ratios for psychosis, we used propensity scores to match patients who received methylphenidate with patients who received amphetamine in each database, compared the incidence of psychosis between the two stimulant groups, and then pooled the results across the two databases.

RESULTS

We assessed 337,919 adolescents and young adults who received a prescription for a stimulant for ADHD. The study population consisted of 221,846 patients with 143,286 person-years of follow up; 110,923 patients taking methylphenidate were matched with 110,923 patients taking amphetamines. There were 343 episodes of psychosis (with an episode defined as a new diagnosis code for psychosis and a prescription for an antipsychotic medication) in the matched populations (2.4 per 1000 person-years): 106 episodes (0.10%) in the methylphenidate group and 237 episodes (0.21%) in the amphetamine group (hazard ratio with amphetamine use, 1.65; 95% confidence interval, 1.31 to 2.09).

CONCLUSIONS

Among adolescents and young adults with ADHD who were receiving prescription stimulants, new-onset psychosis occurred in approximately 1 in 660 patients. Amphetamine use was associated with a greater risk of psychosis than methylphenidate. (Funded by the National Institute of Mental Health and others.).

Time trends in US cannabis use and cannabis use disorders overall and by sociodemographic subgroups: a narrative review and new findings

Background: Due to significant comorbidity and impairment associated with cannabis use and cannabis use disorder, understanding time trends in cannabis use and cannabis use disorder is an important public health priority.Objectives: To identify trends in cannabis use and cannabis use disorder overall, and by sociodemographic subgroup.Methods: Narrative review of published findings on trends in cannabis use and cannabis use disorders in data from repeated cross-sectional US general population surveys. In addition, in National Epidemiologic Survey on Alcohol and Related Conditions (NESARC; 2002-2002) and NESARC-III (2012-2013) data, logistic regression was used to examine whether trends differed between subgroups of adults.Results: The review showed that in adults, cannabis use increased over the past decade overall and within sociodemographic subgroups (gender, age, race/ethnicity, income, education, marital status, urbanicity, region, pregnancy status, disability status), with greater increases in men and disabled adults. Most sources also indicated significant increases in cannabis use disorders. New analysis showed significantly greater increases in adult cannabis use and cannabis use disorder in men (p ≤ .0001); young adults (p < .05); Blacks (vs. Whites, p < .01); low income groups (p < .001); never-married p ≤ .0001), and urban residents (p < .05). In adolescents, cannabis use generally decreased, although recent increases were observed in older and non-White adolescents.Conclusion: Cannabis use and cannabis use disorder are increasing in adults, with specific sociodemographic groups at higher risk, and may be increasing in some adolescent subgroups. Studies should determine mechanisms for differential trends to provide information to policymakers and enable informed decisions on cannabis legalization and service planning.

African-American Women's Tobacco and Marijuana Use: The Effects of Social Context and Substance Use Perceptions

BACKGROUND

Despite the status of tobacco and marijuana as two of the most commonly used substances in the U.S., both have detrimental health and social consequences for disfranchized African-Americans. Substance use may be shaped by social contextual influences from families and peers in African-American communities, and little research has examined perceptions of wrongfulness, harms, and dangers associated with daily tobacco and marijuana use among African-American women.

OBJECTIVES

This study explores the effects of African-American women's social context and substance use perceptions (wrongfulness/harmfulness/dangerousness) on daily tobacco and marijuana use.

METHODS

Survey data was collected in-person from 521 African-American women. Multivariate logistic models identified the significant correlates of women's daily use of tobacco and marijuana in the past six months.

RESULTS

52.59% of participants reported daily tobacco use and 10.56% used marijuana daily. Multivariate models indicated that women were more likely to be daily tobacco users if they had a family member with a substance use problem or perceived tobacco use to be wrong, harmful, or more dangerous than marijuana. In the models with marijuana as the dependent variable, women who lived with a person who used drugs were more likely to use marijuana daily. Perceiving marijuana use as wrong or harmful to one's health was protective against daily marijuana use.

CONCLUSIONS

Findings stress the need for prevention and intervention efforts for African-American women that highlight social context influences and promote greater awareness of the health risks associated with daily tobacco and marijuana use.

Trends in marijuana use among pregnant women with and without nausea and vomiting in pregnancy, 2009-2016

BACKGROUND

Cross-sectional studies indicate an elevated prevalence of prenatal marijuana use in women with nausea and vomiting in pregnancy (NVP). However, it is unknown whether differences in marijuana use by NVP status have persisted over time as marijuana becomes more acceptable and accessible and prenatal use increases overall. We compared trends in prenatal marijuana use by NVP status in the first trimester of pregnancy using data from Kaiser Permanente Northern California's (KPNC) large healthcare system.

METHODS

The sample comprised KPNC pregnant women aged ≥12 who completed a self-administered questionnaire on marijuana use and a urine toxicology test for cannabis during standard prenatal care from 2009 to 2016. The annual prevalence of marijuana use via self-report or toxicology by NVP status was estimated using Poisson regression with a log link function, adjusting for sociodemographics and parity. We tested for linear trends and differences in trends by NVP.

RESULTS

Of 220,510 pregnancies, 38,831 (17.6%) had an NVP diagnosis. Prenatal marijuana use was elevated each year among women with NVP. The adjusted prevalence of use increased significantly from 2009 to 2016 at an annual rate of 1.086 (95%CI = 1.069-1.104) among women with NVP, from 6.5% (95%CI = 5.7%-7.2%) to 11.1% (95%CI = 0.2%-12.0%), and 1.069 (95%CI = 1.059-1.080) among women without NVP, from 3.4% (95%CI = 3.2%-3.7%) to 5.8% (95%CI = 5.5%-6.1%). Trends did not vary by NVP status.

DISCUSSION

The prevalence of prenatal marijuana use has remained elevated over time among women with NVP. Clinicians should ask pregnant patients about their reasons for marijuana use and treat NVP with evidence-based interventions.

Nation-scale primary prevention to reduce newly incident adolescent drug use: the issue of lag time

Background

There is limited evidence about the effects of United States (US) nation-level policy changes on the incidence of alcohol drinking and tobacco smoking. To investigate the potential primary prevention effects on precocious drug use and to clarify lag-time issues, we estimated incidence rates for specified intervals anticipating and lagging after drug policy enactment. Our hypotheses are (a) reductions in underage drinking or smoking onset and (b) increases of incidence at the legal age (i.e., 21 for drinking and 18 for smoking).

Methods

The study population is 12–23-year-old non-institutionalized US civilian residents. Estimates are from 30 community samples drawn to be nationally representative for the US National Surveys on Drug Use and Health 1979–2015. Estimates were year-by-year annual incidence rates for alcohol drinking and tobacco smoking by 12–23-year-olds, age by age. Meta-regressions estimate age-specific incidence over time.

Results

Incidence of underage alcohol drinking declined and followed a trend line that started before 1984 enactment of the National Minimum Drinking Age Act, but increased drinking incidence for 21 year olds was observed approximately 10 years after policy enactment. Eight years after the Synar amendment enactment, evidence of reduced smoking incidence started to emerge. Among 18 year olds, a slight increase in tobacco smoking incidence occurred about 10 years after the Synar amendment.

Conclusion

Once nation-level policies affecting drug sales to minors are enacted, one might have to wait almost a decade before seeing tangible policy effects on drug use incidence rates.

An Update of Current Cannabis-Based Pharmaceuticals in Pain Medicine

Cannabis users have long reported therapeutic properties of the plant for a variety of conditions, some of which include nausea, emesis, seizures, cancer, neurogenic diseases and pain control. Research has elucidated many cannabinoid pharmacodynamic and pharmacokinetic properties, expanding the potential use of cannabinoids as a medical therapy. Due to the inconsistent delivery and control of the active components involved with smoking, pharmaceutical companies are investigating and prioritizing routes other than smoke inhalation for therapeutic use of cannabinoids. In this relatively new field of pharmaceutical development, ongoing drug development promises great benefit from targeted endocannabinoid receptor agonism. Available in Canada and Europe, nabiximols, a specific extract from the Cannabis plant, has demonstrated great benefit in the treatment of pain related to spasticity in multiple sclerosis, cancer and otherwise chronic pain conditions. The cannabidiol oral solution Epidiolex®, which is available in the USA, is indicated for management of refractory epilepsy but may offer therapeutic relief to chronic pain conditions as well. Current investigative drugs, such as those developed by Cara Therapeutics and Zynerba Pharmaceuticals, are synthetic cannabinoids which show promise to specifically target neuropsychiatric conditions and chronic pain symptoms such as neuropathy and allodynia. The objective of this review is to provide clinicians with an update of currently available and promising developmental cannabis pharmaceutical derivatives which may stand to greatly benefit patients with otherwise difficult-to-treat chronic conditions.

Cannabis Use and Anxiety Sensitivity in Relation to Physical Health and Functioning in post-9/11 Veterans

Frequency of cannabis use and cognitive vulnerabilities such as anxiety sensitivity (i.e., the fear of bodily sensations), have been independently linked with poor physical health, however the interplay between these health-mental health processes may compound poor physical health and functioning in cannabis users. Thus, the current study evaluated the direct and interactive effects of cannabis use frequency and anxiety sensitivity on physical health and functioning among cannabis-using veterans. Participants (N = 138) were post-9/11 United States veterans recruited from a Veterans Affairs hospital who reported cannabis use in the past six months. Cannabis use frequency in the past month and anxiety sensitivity were significantly negatively correlated with perceived overall physical health. There was a significant interaction between cannabis use frequency and anxiety sensitivity, such that more frequent cannabis use was associated with poorer overall health and role functioning due to health problems among veterans with higher anxiety sensitivity (but not lower). Findings suggest that anxiety sensitivity is a cognitive vulnerability linked to poor perceived physical health and impairment among frequent cannabis users and could be targeted, along with cannabis use, for health-promotion in cannabis users.

Cannabinoid exposure during pregnancy and its impact on immune function

Cannabinoids are the most commonly abused illicit drugs worldwide. While cannabis can be beneficial for certain heath conditions, abuse of potent synthetic cannabinoids has been on the rise. Exposure to cannabinoids is also prevalent in women of child-bearing age and pregnant women. These compounds can cross the placental barrier and directly affect the fetus. They mediate their effects primarily through G-protein coupled cannabinoid receptors, CB1 and CB2. In addition to significant neurological effects, cannabinoids can trigger robust immunomodulation by altering cytokine levels, causing apoptosis of lymphoid cells and inducing suppressor cells of the immune system. Profound effects of cannabinoids on the immune system as discussed in this review, suggest that maternal exposure during pregnancy could lead to dysregulation of innate and adaptive immune system of developing fetus and offspring potentially leading to weakening of immune defenses against infections and cancer later in life. Emerging evidence also indicates the underlying role of epigenetic mechanisms causing long-lasting impact following cannabinoid exposure in utero.

Does Marijuana Use at Ages 16-18 Predict Initiation of Daily Cigarette Smoking in Late Adolescence and Early Adulthood? A Propensity Score Analysis of Add Health Data

Given the declining trend in adolescent cigarette smoking and increase in general access to marijuana, it is important to examine whether marijuana use in adolescence is a risk factor for subsequent cigarette smoking in late adolescence and early adulthood. Preliminary evidence from a very small number of studies suggests that marijuana use during adolescence is associated with later smoking; however, to control confounding, previously published studies used regression adjustment, which is susceptible to extrapolation when the confounder distributions differ between adolescent marijuana users and non-users. The current study uses propensity score weighting, a causal inference method not previously used in this area of research, to weight participants based on their estimated probability of exposure given confounders (the propensity score) to balance observed confounders between marijuana users and non-users. The sample consists of participants of Add Health (a nationally representative dataset of youth followed into adulthood) who were 16-18, with no history of daily cigarette smoking at baseline (n = 2928 for female and 2731 for male sub-samples). We assessed the effect of adolescent marijuana use (exposure, ascertained at wave 1) on any daily cigarette smoking during the subsequent 13 years (outcome, ascertained at wave 4). Analyses suggest that for females (but not males) who used marijuana in adolescence, marijuana use increased the risk for subsequent daily smoking: OR = 1.71, 95% CI = (1.13, 2.59). We recommend that adolescent marijuana use be viewed as a possible risk factor for subsequent initiation of daily cigarette smoking in women.