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Zhang C, Slawek DE, Ross J, Zolotov Y, Castillo F, Levin FR, Sohler NL, Minami H, Cunningham CO, Starrels JL, Arnsten JH. Factors Associated with Medical Cannabis Use After Certification: A Three-Month Longitudinal Study. Cannabis Cannabinoid Res 2024; 9:e859-e869. [PMID: 36961410 PMCID: PMC11295650 DOI: 10.1089/can.2022.0248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023] Open
Abstract
Background: Over the past decade, there has been increased utilization of medical cannabis (MC) in the United States. Few studies have described sociodemographic and clinical factors associated with MC use after certification and more specifically, factors associated with use of MC products with different cannabinoid profiles. Methods: We conducted a longitudinal cohort study of adults (N=225) with chronic or severe pain on opioids who were newly certified for MC in New York State and enrolled in the study between November 2018 and January 2022. We collected data over participants' first 3 months in the study, from web-based assessment of MC use every 2 weeks (unit of analysis). We used generalized estimating equation models to examine associations of sociodemographic and clinical factors with (1) MC use (vs. no MC use) and (2) use of MC products with different cannabinoid profiles. Results: On average, 29% of the participants used predominantly high delta-9-tetrahydrocannabinol (THC) MC products within the first 3 months of follow-up, 30% used other MC products, and 41% did not use MC products. Non-Hispanic White race, pain at multiple sites, and past 30-day sedative use were associated with a higher likelihood of MC use (vs. no MC use). Current tobacco use, unregulated cannabis use, and enrollment in the study during the COVID-19 pandemic were associated with a lower likelihood of MC use (vs. no MC use). Among participants reporting MC use, female gender and older age were associated with a lower likelihood of using predominantly high-THC MC products (vs. other MC products). Conclusion: White individuals were more likely to use MC after certification, which may be owing to access and cost issues. The findings that sedative use was associated with greater MC use, but tobacco and unregulated cannabis were associated with less MC use, may imply synergism and substitution that warrant further research. From the policy perspective, additional measures are needed to ensure equitable availability of and access to MC. Health practitioners should check patients' history and current use of sedative, tobacco, and unregulated cannabis before providing an MC recommendation and counsel patients on safe cannabis use. clinicaltrials.gov (NCT03268551).
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Affiliation(s)
- Chenshu Zhang
- Division of General Internal Medicine, Department of Medicine, Montefiore Health System, Bronx, New York, USA
- Department of Medicine, Einstein College of Medicine, New York, New York, USA
| | - Deepika E. Slawek
- Division of General Internal Medicine, Department of Medicine, Montefiore Health System, Bronx, New York, USA
- Department of Medicine, Einstein College of Medicine, New York, New York, USA
| | - Jonathan Ross
- Division of General Internal Medicine, Department of Medicine, Montefiore Health System, Bronx, New York, USA
- Department of Medicine, Einstein College of Medicine, New York, New York, USA
| | - Yuval Zolotov
- Division of General Internal Medicine, Department of Medicine, Montefiore Health System, Bronx, New York, USA
- Department of Medicine, Einstein College of Medicine, New York, New York, USA
| | - Felipe Castillo
- Division on Substance Use Disorders, NY State Psychiatric Institute, New York, New York, USA
- Department of Psychiatry, Columbia University Irving Medical Center, New York, New York, USA
| | - Frances R. Levin
- Division on Substance Use Disorders, NY State Psychiatric Institute, New York, New York, USA
- Department of Psychiatry, Columbia University Irving Medical Center, New York, New York, USA
| | - Nancy L. Sohler
- Department of Community Health and Social Medicine, City University of New York, New York, New York, USA
| | - Haruka Minami
- Department of Psychology, Fordham University, Bronx, New York, USA
| | | | - Joanna L. Starrels
- Division of General Internal Medicine, Department of Medicine, Montefiore Health System, Bronx, New York, USA
- Department of Medicine, Einstein College of Medicine, New York, New York, USA
| | - Julia H. Arnsten
- Division of General Internal Medicine, Department of Medicine, Montefiore Health System, Bronx, New York, USA
- Department of Medicine, Einstein College of Medicine, New York, New York, USA
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2
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Boehnke KF, Sinclair R, Gordon F, Hosanagar A, Roehler DR, Smith T, Hoots B. Trends in U.S. Medical Cannabis Registrations, Authorizing Clinicians, and Reasons for Use From 2020 to 2022. Ann Intern Med 2024; 177:458-466. [PMID: 38588545 DOI: 10.7326/m23-2811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND As medical cannabis availability increases, up-to-date trends in medical cannabis licensure can inform clinical policy and care. OBJECTIVE To describe current trends in medical cannabis licensure in the United States. DESIGN Ecological study with repeated measures. SETTING Publicly available state registry data from 2020 to 2022. PARTICIPANTS People with medical cannabis licenses and clinicians authorizing cannabis licenses in the United States. MEASUREMENTS Total patient volume and prevalence per 10 000 persons in the total population, symptoms or conditions qualifying patients for licensure (that is, patient-reported qualifying conditions), and number of authorizing clinicians. RESULTS In 2022, of 39 jurisdictions allowing medical cannabis use, 34 reported patient numbers, 19 reported patient-reported qualifying conditions, and 29 reported authorizing clinician numbers. Enrolled patients increased 33.3% from 2020 (3 099 096) to 2022 (4 132 098), with a corresponding 23.0% increase in the population prevalence of patients (175.0 per 10 000 in 2020 to 215.2 per 10 000 in 2022). However, 13 of 15 jurisdictions with nonmedical adult-use laws had decreased enrollment from 2020 to 2022. The proportion of patient-reported qualifying conditions with substantial or conclusive evidence of therapeutic value decreased from 70.4% (2020) to 53.8% (2022). Chronic pain was the most common patient-reported qualifying condition in 2022 (48.4%), followed by anxiety (14.2%) and posttraumatic stress disorder (13.0%). In 2022, the United States had 29 500 authorizing clinicians (7.7 per 1000 patients), 53.5% of whom were physicians. The most common specialties reported were internal or family medicine (63.4%), physical medicine and rehabilitation (9.1%), and anesthesia or pain (7.9%). LIMITATION Missing data (for example, from California), descriptive analysis, lack of information on individual use patterns, and changing evidence base. CONCLUSION Enrollment in medical cannabis programs increased overall but generally decreased in jurisdictions with nonmedical adult-use laws. Use for conditions or symptoms without a strong evidence basis continues to increase. Given these trends, more research is needed to better understand the risks and benefits of medical cannabis. PRIMARY FUNDING SOURCE National Institute on Drug Abuse of the National Institutes of Health.
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Affiliation(s)
- Kevin F Boehnke
- Anesthesiology Department, Chronic Pain and Fatigue Research Center, University of Michigan Medical School, Ann Arbor, Michigan (K.F.B., F.G., T.S.)
| | - Rachel Sinclair
- Cannabis Strategy Unit, Division of Overdose Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia, and Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee (R.S.)
| | - Felicia Gordon
- Anesthesiology Department, Chronic Pain and Fatigue Research Center, University of Michigan Medical School, Ann Arbor, Michigan (K.F.B., F.G., T.S.)
| | - Avinash Hosanagar
- Veterans Affairs Ann Arbor Healthcare System and Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan (A.H.)
| | - Douglas R Roehler
- Cannabis Strategy Unit, Division of Overdose Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia (D.R.R., B.H.)
| | - Tristin Smith
- Anesthesiology Department, Chronic Pain and Fatigue Research Center, University of Michigan Medical School, Ann Arbor, Michigan (K.F.B., F.G., T.S.)
| | - Brooke Hoots
- Cannabis Strategy Unit, Division of Overdose Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia (D.R.R., B.H.)
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Yaskewich DM. State licenses for medical marijuana dispensaries: neighborhood-level determinants of applicant quality in Missouri. J Cannabis Res 2024; 6:17. [PMID: 38532499 DOI: 10.1186/s42238-024-00223-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 02/22/2024] [Indexed: 03/28/2024] Open
Abstract
BACKGROUND When state governments impose quotas on commercial marijuana licenses, regulatory commissions use an application process to assess the feasibility of prospective businesses. Decisions on license applications are often met with formal appeals and legal challenges from rejected applicants. Although prior research has examined substate disparities in the availability of marijuana dispensaries, less attention has been given to the quality of license applications. The present study analyzed the relationship between neighborhood-level characteristics and the quality of prospective dispensary businesses. METHODS During Missouri's first applicant pool for medical marijuana dispensaries in 2019, a total of 606 census tracts contained the location site of at least one dispensary applicant. Using data from the Missouri Department of Health and Senior Services and the American Community Survey, fractional and binary logistic regression models were used to estimate the relationship between census-tract characteristics and application outcomes. RESULTS License applications received higher evaluation scores when proposed dispensary sites were in census tracts with greater population densities and no majority in racial/ethnic composition. Census tracts with poorer socioeconomic conditions attracted a disproportionate share of low-scoring applicants from the bottom quartile of scores. These effects were stronger for certain application subsections, particularly those assessing the quality of an applicant's business plan and on-site security. CONCLUSIONS Some communities tend to attract prospective license holders who possess better quality resources, business practices, and industry experience. State disparities in commercial licensing requirements and application processes may lead to the inequities in legal product access found in some prior studies.
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Affiliation(s)
- David M Yaskewich
- Southeast Missouri State University, One University Plaza; Mailstop #5845, Cape Girardeau, MO, 63701, USA.
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Freitag EW, Zolotov Y, Annam J, Labins J, Yamada JM, Jillani SM, Arnsten JH, Slawek DE. Available but inaccessible: patient experiences during the first 2 years of a primary care-based medical cannabis program at an academic medical center. Harm Reduct J 2024; 21:1. [PMID: 38166921 PMCID: PMC10763347 DOI: 10.1186/s12954-023-00919-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 12/19/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Medical cannabis use and public acceptance in the United States have increased over the past 25 years. However, access to medical cannabis remains limited, particularly for underserved populations. To understand how patients experience medical cannabis accessibility, we measured medical cannabis use and barriers to use after medical cannabis certification in an urban safety-net academic medical center. METHODS We conducted a retrospective cohort study among patients seen in Montefiore's Medical Cannabis Program (MMCP) from 2017 to 2019. Patient demographic and clinical characteristics, as well purchase history of medical cannabis, were extracted from electronic medical records. We also administered a phone questionnaire to a subset of patients to assess usage patterns, effectiveness, and barriers to medical cannabis use. RESULTS Among 562 patients who were newly certified for medical cannabis between 2017 and 2019, 45% purchased medical cannabis, while 55% did not. Patients who purchased medical cannabis were more likely to be white and have private insurance or Medicare. Unregulated cannabis use and current tobacco use were less common among those who purchased medical cannabis. In multivariable logistic regression analysis, unregulated cannabis use remained negatively associated with purchasing medical cannabis. Patients reported that affordability and dispensary accessibility were their main barriers to purchasing medical cannabis. CONCLUSION Among patients certified for medical cannabis use, fewer than half purchased medical cannabis after certification. Improving access to medical cannabis is crucial for ensuring equitable access to regulated cannabis, and to reducing unregulated cannabis use.
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Affiliation(s)
| | - Yuval Zolotov
- Division of General Internal Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, 111 E 210th St, Bronx, NY, 10467, USA
| | - Jayabhargav Annam
- Division of General Internal Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, 111 E 210th St, Bronx, NY, 10467, USA
| | - Jaqueline Labins
- Division of General Internal Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, 111 E 210th St, Bronx, NY, 10467, USA
| | - Jaclyn M Yamada
- Division of General Internal Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, 111 E 210th St, Bronx, NY, 10467, USA
| | - Syeda Masharab Jillani
- Division of General Internal Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, 111 E 210th St, Bronx, NY, 10467, USA
| | - Julia H Arnsten
- Division of General Internal Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, 111 E 210th St, Bronx, NY, 10467, USA
| | - Deepika E Slawek
- Division of General Internal Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, 111 E 210th St, Bronx, NY, 10467, USA.
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Williams AR, Mauro CM, Feng T, Waples J, Martins SS, Haney M. Adult Medical Cannabinoid Use and Changes in Prescription Controlled Substance Use. Cannabis Cannabinoid Res 2023; 8:933-941. [PMID: 35486854 PMCID: PMC10589493 DOI: 10.1089/can.2021.0212] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Introduction: Nonopioid-based strategies for managing chronic noncancer pain are needed to help reduce overdose deaths. Although lab studies and population-level data suggest that cannabinoids could provide opioid-sparing effects, among medical cannabis participants they may also impact overdose risk by modifying other controlled substance use such as sedative hypnotics. However, no study has combined observational data at the individual level to empirically address interactions between the use of cannabinoids and prescribed controlled substances. Methods: Electronic health records, including prescription drug monitoring program data, from a large multisite medical cannabis program in New York State were abstracted for all participants with noncancer pain and recently prescribed noncannabinoid controlled substances who completed a new intake visit from April 15, 2018-April 14, 2019 and who remained actively in treatment for >180 days. Participants were partitioned into two samples: those with recent opioid use and those with active opioid use and co-use of sedative hypnotics. A patient-month level analysis assessed total average equivalent milligrams by class of drug (i.e., cannabinoid distinguishing tetrahydrocannabinol [THC] vs. cannabidiol [CBD], opioids, and sedative-hypnotics) received as a time-varying outcome measure across each 30-day "month" period postintake for at least 6 months for all participants. Results: Sample 1 of 285 opioid users were 61.1 years of age (±13.5), 57.5% female, and using an average of 49.7 (±98.5) morphine equivalents daily at intake. Unadjusted analyses found a modest decline in morphine equivalents to 43.9 mg (±94.1 mg) from 49.7 (±98.5) in month 1 (p=0.047) while receiving relatively low doses of THC (2.93 mg/day) and CBD (2.15 mg/day). Sample 2 of 95 opioid and sedative-hypnotic users were 60.9 years of age (±13.1), 63.2% female, and using an average of 86.6 (±136.2) morphine equivalents daily, and an average of 4.3 (±5.6) lorazepam equivalents. Unadjusted analyses did not find significant changes in either morphine equivalents (p=0.81) or lorazepam equivalents (p=0.980), and patients similarly received relatively low doses of THC (2.32 mg/day) and CBD (2.24 mg/day). Conclusions: Findings demonstrated minimal to no change in either opioids or sedative hypnotics over the 6 months of medical cannabis use but may be limited by low retention rates, external generalizability, and an inability to account for nonprescribed substance use.
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Affiliation(s)
- Arthur Robin Williams
- Department of Psychiatry, New York State Psychiatric Institute, Columbia University Medical Center, New York, New York, USA
- Research Foundation for Mental Hygiene, New York, New York, USA
| | - Christine M. Mauro
- Department of Biostatistics, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Tianshu Feng
- Research Foundation for Mental Hygiene, New York, New York, USA
| | - Josef Waples
- City University of New York School of Professional Studies, New York, New York, USA
| | - Silvia S. Martins
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Margaret Haney
- Research Foundation for Mental Hygiene, New York, New York, USA
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Sedani AE, Campbell JE, Beebe LA. Cannabis use among cancer survivors in 22 states: Results from the Behavioral Risk Factor Surveillance System, 2020. Cancer 2023; 129:2499-2513. [PMID: 37029457 DOI: 10.1002/cncr.34793] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 03/07/2023] [Accepted: 03/22/2023] [Indexed: 04/09/2023]
Abstract
BACKGROUND This study identified factors associated with recent cannabis use and cannabis use for medical purposes among cancer survivors relative to individuals without a history of cancer. METHODS Data from the Behavioral Risk Factor Surveillance System were analyzed for the 22 states completing the optional cannabis module in 2020. Weighted multiple logistic regression was performed to explore variables associated with past 30-day cannabis use and cannabis use for medical purposes, stratified by history of cancer. Covariates included state-level cannabis policy, sociodemographic characteristics, health status indicators, and substance use. RESULTS Cannabis use was lower among cancer survivors compared to individuals with no history of cancer (7.57% vs. 10.83%). However, a higher proportion of cancer survivors reported use for medical purposes (82.23% vs. 62.58%). After adjusting for state-level policy, biological sex, age, educational attainment, self-reported race/ethnicity, home ownership, mental health status and physical health status, current smoking (odds ratio [OR], 5.14 vs. 3.74) and binge drinking (OR, 2.71 vs. 2.69) were associated with cannabis use in both groups. Characteristics associated with medical cannabis use varied for the two groups; however, daily use (20-30 days; OR, 1.72 vs. 2.43) was associated with cannabis use for medical purposes in both groups after adjusting for other variables in the model. CONCLUSIONS A high proportion of individuals report cannabis use for medical purposes with higher rates among cancer survivors. Findings support the urgent need for ongoing cannabis research to better understand and inform its use for medical purposes, as well as the development of high-quality standardized education materials and clinical practice guidelines.
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Affiliation(s)
- Ami E Sedani
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Janis E Campbell
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Laura A Beebe
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
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Slawek DE, Althouse AD, Feldman R, Arnsten JH, Bulls HW, Liebschutz JM, Nugent SM, Orris SR, Rohac R, Starrels JL, Morasco BJ, Kansagara D, Merlin JS. Cannabis dispensary staff approaches to counseling on potential contraindications to cannabis use: insights from a national self-report survey. BMC PRIMARY CARE 2023; 24:145. [PMID: 37442944 PMCID: PMC10347704 DOI: 10.1186/s12875-023-02095-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 06/28/2023] [Indexed: 07/15/2023]
Abstract
BACKGROUND Legal cannabis is available in more than half of the United States. Health care professionals (HCPs) rarely give recommendations on dosing or safety of cannabis due to limits imposed by policy and lack of knowledge. Customer-facing cannabis dispensary staff, including clinicians (pharmacists, nurses, physician's assistants), communicate these recommendations in the absence of HCP recommendations. Little is known about how dispensary staff approach individuals with complex medical and psychiatric comorbidities. Using responses from a national survey, we describe how cannabis dispensary staff counsel customers with medical and psychiatric comorbidities on cannabis use and examine whether state-specific cannabis policy is associated with advice given to customers. METHODS National, cross-sectional online survey study from February 13, 2020 to October 2, 2020 of dispensary staff at dispensaries that sell delta-9-tetrahydrocannabinol containing products. Measures include responses to survey questions about how they approach customers with medical and psychiatric comorbidities; state medicalization score (scale 0-100; higher score indicates more similarity to regulation of traditional pharmacies); legalized adult-use cannabis (yes/no). We conducted multiple mixed effects multivariable logistic regression analyses to understand relationships between state medicalization and dispensary employees' perspectives. RESULTS Of 434 eligible respondents, most were budtenders (40%) or managers (32%), and a minority were clinicians (18%). State medicalization score was not associated with responses to most survey questions. It was associated with increased odds of encouraging customers with medical comorbidities to inform their traditional HCP of cannabis use (Odds ratio [OR]=1.2, 95% confidence interval [CI] 1.0-1.4, p=0.03) and reduced odds of recommending cannabis for individuals with cannabis use disorder (CUD) (OR=0.8, 95% CI 0.7-1.0, p=0.04). Working in a state with legalized adult-use cannabis was associated with recommending traditional health care instead of cannabis in those with serious mental illness (OR 2.2, 95% CI 1.1-4.7, p=0.04). Less than half of respondents believed they had encountered CUD (49%), and over a quarter did not believe cannabis is addictive (26%). CONCLUSIONS When managing cannabis dosing and safety in customers with medical and psychiatric comorbidity, dispensary staff preferred involving individuals' traditional HCPs. Dispensary staff were skeptical of cannabis being addictive. While state regulations of dispensaries may impact the products individuals have access to, they were not associated with recommendations that dispensary staff gave to customers. Alternative explanations for dispensary recommendations may include regional or store-level variation not captured in this analysis.
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Affiliation(s)
- Deepika E Slawek
- Division of General Internal Medicine, Albert Einstein College of Medicine, Bronx, NY, USA.
- Montefiore Medical Center/Albert Einstein College of Medicine, 111 E 210th St, Bronx, NY, 10467, USA.
| | - Andrew D Althouse
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA, USA
| | - Robert Feldman
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA, USA
| | - Julia H Arnsten
- Division of General Internal Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
- Montefiore Medical Center/Albert Einstein College of Medicine, 111 E 210th St, Bronx, NY, 10467, USA
| | - Hailey W Bulls
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA, USA
- CHAllenges in Managing and Preventing Pain (CHAMPP) Clinical Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jane M Liebschutz
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA, USA
| | - Shannon M Nugent
- Department of Psychiatry, Oregon Health and Science University, Portland, OR, USA
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
| | - Steven R Orris
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA, USA
| | - Rebecca Rohac
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA, USA
| | - Joanna L Starrels
- Division of General Internal Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Benjamin J Morasco
- Department of Psychiatry, Oregon Health and Science University, Portland, OR, USA
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
| | - Devan Kansagara
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
- Department of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Jessica S Merlin
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA, USA
- CHAllenges in Managing and Preventing Pain (CHAMPP) Clinical Research Center, University of Pittsburgh, Pittsburgh, PA, USA
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Woerdenbag HJ, Olinga P, Kok EA, Brugman DAP, van Ark UF, Ramcharan AS, Lebbink PW, Hoogwater FJH, Knapen DG, de Groot DJA, Nijkamp MW. Potential, Limitations and Risks of Cannabis-Derived Products in Cancer Treatment. Cancers (Basel) 2023; 15:cancers15072119. [PMID: 37046779 PMCID: PMC10093248 DOI: 10.3390/cancers15072119] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 03/31/2023] [Accepted: 03/31/2023] [Indexed: 04/05/2023] Open
Abstract
The application of cannabis products in oncology receives interest, especially from patients. Despite the plethora of research data available, the added value in curative or palliative cancer care and the possible risks involved are insufficiently proven and therefore a matter of debate. We aim to give a recommendation on the position of cannabis products in clinical oncology by assessing recent literature. Various types of cannabis products, characteristics, quality and pharmacology are discussed. Standardisation is essential for reliable and reproducible quality. The oromucosal/sublingual route of administration is preferred over inhalation and drinking tea. Cannabinoids may inhibit efflux transporters and drug-metabolising enzymes, possibly inducing pharmacokinetic interactions with anticancer drugs being substrates for these proteins. This may enhance the cytostatic effect and/or drug-related adverse effects. Reversely, it may enable dose reduction. Similar interactions are likely with drugs used for symptom management treating pain, nausea, vomiting and anorexia. Cannabis products are usually well tolerated and may improve the quality of life of patients with cancer (although not unambiguously proven). The combination with immunotherapy seems undesirable because of the immunosuppressive action of cannabinoids. Further clinical research is warranted to scientifically support (refraining from) using cannabis products in patients with cancer.
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Affiliation(s)
- Herman J. Woerdenbag
- Department of Pharmaceutical Technology and Biopharmacy, University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands
| | - Peter Olinga
- Department of Pharmaceutical Technology and Biopharmacy, University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands
| | - Ellen A. Kok
- Department of Pharmaceutical Technology and Biopharmacy, University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands
| | - Donald A. P. Brugman
- Department of Pharmaceutical Technology and Biopharmacy, University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands
| | - Ulrike F. van Ark
- Department of Pharmaceutical Technology and Biopharmacy, University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands
| | | | - Paul W. Lebbink
- Transvaal Apotheek, Kempstraat 113, 2572 GC Den Haag, The Netherlands
| | - Frederik J. H. Hoogwater
- Department of Surgery, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Daan G. Knapen
- Department of Medical Oncology, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Derk Jan A. de Groot
- Department of Medical Oncology, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Maarten W. Nijkamp
- Department of Surgery, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
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Blanchette JG, Pacula RL, Smart R, Lira MC, Boustead AE, Caulkins JP, Kilmer B, Kerr WC, Treffers R, Naimi TS. Rating the comparative efficacy of state-level cannabis policies on recreational cannabis markets in the United States. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 106:103744. [DOI: 10.1016/j.drugpo.2022.103744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 05/04/2022] [Accepted: 05/08/2022] [Indexed: 10/18/2022]
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10
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Boehnke KF, Dean O, Haffajee RL, Hosanagar A. U.S. Trends in Registration for Medical Cannabis and Reasons for Use From 2016 to 2020 : An Observational Study. Ann Intern Med 2022; 175:945-951. [PMID: 35696691 DOI: 10.7326/m22-0217] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Cannabis policy liberalization has increased cannabis availability for medical or recreational purposes. Up-to-date trends in medical cannabis licensure can inform clinical policy and care. OBJECTIVE To describe recent trends in medical cannabis licensure in the United States. DESIGN Ecological study with repeated measures. SETTING State registry data via state reports and data requests on medical cannabis licensure from 2016 to 2020. PARTICIPANTS Medical cannabis patients (persons with medical cannabis licenses) in the United States. MEASUREMENTS Total patient volume, patients per 10 000 of total population, and patient-reported qualifying conditions (that is, symptoms or conditions qualifying patients for licensure)-including whether these symptoms align with current therapeutic evidence of cannabis-cannabinoid efficacy. RESULTS In 2020, 26 states and Washington, DC reported patient numbers, and 19 states reported patient-reported qualifying conditions. Total enrolled patients increased approximately 4.5-fold from 678 408 in 2016 to 2 974 433 in 2020. Patients per 10 000 total population generally increased from 2016 to 2020, most dramatically in Oklahoma (927.1 patients per 10 000 population). However, enrollment increased in states without recreational legalization (that is, medical-only states), whereas enrollment decreased in 5 of 7 with recreational legalization (that is, recreational states). In 2020, 68.2% of patient-reported qualifying conditions had substantial or conclusive evidence of therapeutic value versus 84.6% in 2016. Chronic pain was the most common patient-reported qualifying condition in 2020 (60.6%), followed by posttraumatic stress disorder (10.6%). LIMITATION Missing state data; lack of rationale for discontinuing medical cannabis licensure. CONCLUSION Enrollment in medical cannabis programs approximately increased 4.5-fold from 2016 to 2020, although enrollment decreased in recreational states. Use for conditions or symptoms without a strong evidence basis increased from 15.4% (2016) to 31.8% (2020). Thoughtful regulatory and clinical strategies are needed to effectively manage this rapidly changing landscape. PRIMARY FUNDING SOURCE National Institute on Drug Abuse of the National Institutes of Health.
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Affiliation(s)
- Kevin F Boehnke
- Anesthesiology Department, Chronic Pain and Fatigue Research Center, University of Michigan Medical School, Ann Arbor, Michigan (K.F.B.)
| | - Owen Dean
- College of Literature, Science, and the Arts, University of Michigan, Ann Arbor, Michigan (O.D.)
| | - Rebecca L Haffajee
- Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health & Human Services, Washington, DC (R.L.H.)
| | - Avinash Hosanagar
- Veterans Affairs Ann Arbor Healthcare System and Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan (A.H.)
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11
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Boehnke KF, Davis AK, McAfee J. Applying Lessons From Cannabis to the Psychedelic Highway. JAMA HEALTH FORUM 2022; 3:e221618. [PMID: 36219016 DOI: 10.1001/jamahealthforum.2022.1618] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Kevin F. Boehnke
- Anesthesiology Department, Chronic Pain and Fatigue Research Center, University of Michigan Medical School, Ann Arbor
| | - Alan K. Davis
- Center for Psychedelic Drug Research and Education, College of Social Work, The Ohio State University, Columbus
- Center for Psychedelic and Consciousness Research, Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jenna McAfee
- Anesthesiology Department, Chronic Pain and Fatigue Research Center, University of Michigan Medical School, Ann Arbor
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12
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Ross J, Yamada J, Slawek D, Starrels JL, Cunningham CO, Arnsten JH. Increasing Access to Safe Medical Cannabis: Establishment of a Medical Cannabis Program in a Safety-Net Academic Medical Center. NEJM CATALYST INNOVATIONS IN CARE DELIVERY 2022; 3:10.1056/cat.21.0373. [PMID: 36172004 PMCID: PMC9512136 DOI: 10.1056/cat.21.0373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Despite numerous challenges, Montefiore Medical Center in New York City implemented a program aimed at providing comprehensive, evidence-based medical cannabis certifications to patients, including those who have been historically disenfranchised, and shares insights from five years of operation.
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Affiliation(s)
- Jonathan Ross
- Assistant Professor of Medicine, Montefiore Health System, Division of General Internal Medicine, Bronx, New York, USA,Assistant Professor of Medicine, Albert Einstein College of Medicine, Division of General Internal Medicine, Bronx, New York, USA
| | - Jaclyn Yamada
- Resident, Northwell Health, New Hyde Park, New York, USA,Former medical student, Albert Einstein College of Medicine, Division of General Internal Medicine, Bronx, New York, USA
| | - Deepika Slawek
- Assistant Professor of Medicine, Montefiore Health System, Division of General Internal Medicine, Bronx, New York, USA,Assistant Professor of Medicine, Albert Einstein College of Medicine, Division of General Internal Medicine, Bronx, New York, USA
| | - Joanna L. Starrels
- Associate Professor of Medicine, Montefiore Health System, Division of General Internal Medicine, Bronx, New York, USA,Associate Professor of Medicine, Albert Einstein College of Medicine, Division of General Internal Medicine, Bronx, New York, USA
| | - Chinazo O. Cunningham
- Professor of Medicine, Family and Social Medicine, and Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Division of General Internal Medicine, Bronx, New York, USA
| | - Julia H. Arnsten
- Professor of Medicine, Epidemiology & Population Health, and Psychiatry and Behavioral Sciences, Montefiore Health System, Division of General Internal Medicine, Bronx, New York, USA,Professor of Medicine, Epidemiology & Population Health, and Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Division of General Internal Medicine, Bronx, New York, USA
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13
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Ross J, Slawek DE, Zhang C, Starrels JL, Levin FR, Sohler NL, Minami H, Arnsten JH, Cunningham CO. First-Year Trajectories of Medical Cannabis Use Among Adults Taking Opioids for Chronic Pain: An Observational Cohort Study. PAIN MEDICINE 2021; 22:3080-3088. [PMID: 34411246 DOI: 10.1093/pm/pnab257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 07/30/2021] [Accepted: 08/12/2021] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To describe first-year trajectories of medical cannabis use and identify characteristics associated with patterns of use in a cohort of adults using opioids for chronic pain. DESIGN Latent class trajectory analysis of a prospective cohort study using data on the 14-day frequency of medical cannabis use. SETTING A large academic medical center and four medical cannabis dispensaries in the New York City metropolitan area. SUBJECTS Adults with chronic pain using opioids and newly certified for medical cannabis in New York between 2018 and 2020. METHODS Using latent class trajectory analysis, we identified clusters of participants based on the 14-day frequency of medical cannabis use. We used logistic regression to determine factors associated with cluster membership, including sociodemographic characteristics, pain, substance use, and mental health symptoms. RESULTS Among 99 participants, the mean age was 53 years; 62% were women, and 52% were White. We identified three clusters of medical cannabis use: infrequent use (n = 30, mean use = 1.5 days/14-day period), occasional use (n = 28, mean = 5.7 days/14-day period), and frequent use (n = 41, mean = 12.1 days/14-day period). Within clusters, use patterns did not vary significantly over 52 weeks. Differences were observed in two sociodemographic variables: Frequent (vs infrequent) use was associated with non-Hispanic White race/ethnicity (adjusted odds ratio 4.54, 95% confidence interval 1.49-14.29), while occasional (vs infrequent) use was associated with employment (adjusted odds ratio 13.84, 95% confidence interval 1.21-158.74). CONCLUSIONS Three clusters of medical cannabis use patterns emerged and were stable over time. Results suggest that structural factors related to race/ethnicity and employment may be major drivers of medical cannabis use, even among adults certified for its use.
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Affiliation(s)
- Jonathan Ross
- Division of General Internal Medicine, Department of Medicine, Montefiore Health System, Bronx, New York, USA
| | - Deepika E Slawek
- Division of General Internal Medicine, Department of Medicine, Montefiore Health System, Bronx, New York, USA
| | - Chenshu Zhang
- Division of General Internal Medicine, Department of Medicine, Montefiore Health System, Bronx, New York, USA
| | - Joanna L Starrels
- Division of General Internal Medicine, Department of Medicine, Montefiore Health System, Bronx, New York, USA
| | - Frances R Levin
- Division on Substance Use Disorders, NY State Psychiatric Institute, New York, New York, USA.,Department of Psychiatry, Columbia University Irving Medical Center, New York, USA
| | - Nancy L Sohler
- Department of Community Health and Social Medicine, City University of New York, New York, New York, USA
| | - Haruka Minami
- Department of Psychology, Fordham University, Bronx, New York, USA
| | - Julia H Arnsten
- Division of General Internal Medicine, Department of Medicine, Montefiore Health System, Bronx, New York, USA
| | - Chinazo O Cunningham
- Division of General Internal Medicine, Department of Medicine, Montefiore Health System, Bronx, New York, USA
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14
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Tormohlen KN, Bicket MC, White S, Barry CL, Stuart EA, Rutkow L, McGinty EE. The State of the Evidence on the Association Between State Cannabis Laws and Opioid-Related Outcomes: a Review. CURRENT ADDICTION REPORTS 2021; 8:538-545. [DOI: 10.1007/s40429-021-00397-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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15
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Merlin JS, Althouse A, Feldman R, Arnsten JH, Bulls HW, Liebschutz JM, Nugent SM, Orris SR, Rohac R, Starrels JL, Morasco BJ, Kansagara D. Analysis of State Cannabis Laws and Dispensary Staff Recommendations to Adults Purchasing Medical Cannabis. JAMA Netw Open 2021; 4:e2124511. [PMID: 34524435 PMCID: PMC8444019 DOI: 10.1001/jamanetworkopen.2021.24511] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
IMPORTANCE Over the last decade, cannabis has become more accessible through the proliferation of dispensaries in states that have legalized its use. Most patients using cannabis for medical purposes report getting advice from dispensaries, yet there has been little exploration of frontline dispensary staff practices. OBJECTIVE To describe the practices of frontline dispensary workers who interact with customers purchasing cannabis for medical purposes and assess whether dispensary practices are associated with medicalization of state cannabis laws (degree to which they resemble regulation of prescription or over-the-counter drugs) and statewide adult use. DESIGN, SETTING, AND PARTICIPANTS This nationwide cross-sectional survey study was conducted from February 13, 2020, to October 2, 2020, using an online survey tool. Potential respondents were eligible if they reported working in a dispensary that sells tetrahydrocannabinol-containing products and interacting with customers about cannabis purchases. MAIN OUTCOMES AND MEASURES Participant responses to questions about formulating customer recommendations and talking to customers about risks. RESULTS The 434 survey responses from 351 unique dispensaries were most often completed by individuals who identified as budtenders (40%), managers (32%), and pharmacists (13%). Most respondents reported basing customer recommendations on the customer's medical condition (74%), the experiences of other customers (70%), the customer's prior experience with cannabis (67%), and the respondent's personal experience (63%); fewer respondents relied on clinician input (40%), cost (45%), or inventory (12%). Most respondents routinely advised customers about safe storage and common adverse effects, but few counseled customers about cannabis use disorder, withdrawal, motor vehicle collision risk, or psychotic reactions. A higher state medicalization score was significantly associated with using employer training (odds ratio, 1.41; 95% CI, 1.18-1.67) and physician or clinician input (odds ratio, 1.23; 95% CI, 1.05-1.43) as a basis for recommendation. Medicalization score was not associated with counseling about cannabis risks. CONCLUSIONS AND RELEVANCE This survey study provides insight into how frontline dispensary staff base cannabis recommendations and counsel about risks. The findings may have utility for clinicians to counsel patients who purchase cannabis, customers who want to be prepared for a dispensary visit, and policy makers whose decisions affect cannabis laws.
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Affiliation(s)
- Jessica S. Merlin
- Challenges in Managing and Preventing Pain Clinical Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Andrew Althouse
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Robert Feldman
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Julia H. Arnsten
- Division of General Internal Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Hailey W. Bulls
- Challenges in Managing and Preventing Pain Clinical Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jane M. Liebschutz
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Shannon M. Nugent
- Department of Psychiatry, Oregon Health and Science University, Portland
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
| | - Steven R. Orris
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Rebecca Rohac
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Joanna L. Starrels
- Division of General Internal Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Benjamin J. Morasco
- Department of Psychiatry, Oregon Health and Science University, Portland
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
| | - Devan Kansagara
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
- Department of Medicine, Oregon Health and Science University, Portland
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