How and why have attitudes about cannabis legalization changed so much?

Hemp-based psychoactive use and risk among young adults: Trend theory, policy, and regulation beyond legality

BACKGROUND

Hemp-based psychoactives comprise a burgeoning legal substance market with rising trends in use across the U.S. and Canada as well as parts of Europe. Currently, scant empirical research on the use of these Novel Psychoactive Substances (NPS) exists. By examining policy, market conditions, consumer uptake, and related risks, this research extends theory on drug trends by describing the regulatory environments that shape the emergence and popularity of psychoactive hemp-based products among young adults.

METHODS

Relying on ethnographic fieldwork of hemp-based markets across 3 U.S. state hemp and cannabis policy contexts as well as in-depth interviews with 40 young adult cannabis consumers recruited across 10 U.S. states, we examined how regulatory conditions shape hemp-based psychoactive markets, trends in their use, and associated risks.

RESULTS

Young adults are motivated to consume hemp-based psychoactives due to the regulatory and market environments that facilitate the production of highly potent products that are inexpensive and easily accessible. States that regulate hemp-based psychoactives as cannabis, do not provide hemp markets with a competitive advantage and as such see minimal uptake. In the absence of hemp specific policies, substantial variations in product potencies, insufficient dosing information, and unscrupulous product packaging practices may increase related risks.

CONCLUSION

Trend theory provides insight into the complex relationships that exist between drug policy, markets, and the proliferation of legal highs. Understanding the contextual significance that both market and regulatory conditions have on legal drug production, distribution, and consumption may better inform approaches to reduce the risks commonly associated with novel psychoactive substances like hemp-based psychoactives.

Media Framing of Causes, Risks, and Policy Solutions for Cannabis-Impaired Driving: Does Medical vs. Non-Medical Cannabis Context Matter?

Driving under the influence of cannabis (DUIC) is a major cause of preventable death and a growing public health concern. News media coverage of DUIC may influence public perceptions of causal factors for DUIC, risks of DUIC, and potential policy solutions. This study examines Israeli news media coverage of DUIC, and contrasts media coverage according to whether news items refer to cannabis use for medical vs. non-medical purposes. We conducted a quantitative content analysis of news articles related to driving accidents and cannabis use (N = 299) from eleven of the highest circulation newspapers in Israel between 2008 and 2020. We apply attribution theory to analyze media coverage of accidents that were linked to medical cannabis, use compared with non-medical use. News items describing DUIC in the context of non-medical (vs. medical) cannabis use were more likely to: (a) emphasize individual causes (vs. social and political); (b) describe drivers in negative terms (vs. neutral or positive); (c) refer to an increased accident risk due to cannabis use (vs. inconclusive or low risk); and (d) call for increased enforcement rather than education. Results show that Israeli news media coverage of cannabis-impaired driving varied significantly depending on whether it referred to cannabis use for medical purposes, or non-medical purposes. News media coverage may influence public perceptions of the risks of DUIC, the factors that are associated with this issue, and potential policy solutions that may reduce the prevalence of DUIC in Israel.

Delta-8- and Delta-9-THC Use Frequency, Use Motives, and Mental Health Outcomes

Use of delta-8-THC ("delta-8") has proliferated after the passage of the 2018 Farm Bill. Yet, research on the mental health effects of this increasingly popular cannabinoid is scant. The current study sought to examine mental health correlates of delta-8 use frequency and motives, investigate whether delta-8 use motives predict use frequency, and compare use motives and problems between delta-8 and traditional cannabis. Participants consisted of 363 self-reported delta-8 users who completed measures of delta-8 use frequency, motives, and problems that were adapted from comparable measures for cannabis, as well as measures of mental health outcomes. Delta-8 use frequency was unrelated to use problems and other mental health outcomes. Delta-8 use frequency was positively associated with social and coping motives, but negatively associated with enhancement and conformity motives. Coping and conformity motives were associated with greater depression, anxiety, insomnia, and delta-8 use problems. Participants were more likely to report coping and enhancement motives for delta-8 use compared to cannabis use, but less likely to report conformity motives. Further longitudinal research is needed to assess causality for associations between delta-8 use frequency, use motives, and mental health outcomes.

Public opinion on the expenditure of adult-use cannabis tax revenue: Evidence from New Jersey

OBJECTIVES

To describe New Jersey residents' relative priorities for the allocation of tax revenue generated by recreational cannabis sales. We aim to assess preferences for public health initiatives, including drug treatment, compared to a range of alternatives, including traditional policing, especially within the social and demographic groupings of people generally most impacted by punitive drug enforcement policies.

METHODS

We collected population-representative survey data four months post-implementation of recreational cannabis sales in New Jersey (N = 1,006). We gauge respondents' top preferences for the allocation of new revenue generated by the legal cannabis market. Using multinomial logistic regression, we assess how various demographic and political factors shape public support for devoting revenue toward public health initiatives.

RESULTS

While priorities are mixed within the sample, we find more general support for funding community-based initiatives in public health, housing, and education than for funding police, courts, and prisons. Among Black residents, the largest proportion chose investments in affordable housing. Regression analysis reveals political orientation as having the most consistent association with expressed preferences, with Republicans favoring investments in traditional law enforcement priorities over other potential funding domains.

CONCLUSIONS

Recreational cannabis legalization is occurring at a rapid pace, yet important context, including how the tax revenue could be invested in communities, remains unclear. Insight into current public opinion on funding priorities suggests a desire for investment in fundamental societal institutions, including education and public health, rather than the punitive enforcement mechanisms that have defined cannabis policy for many decades.

Patterns of cannabis use, perception of harm, and perceived impact of legislative change in an online sample of young adults from Lebanon: insight on recreational users versus dual motive users

BACKGROUND

Lebanon remains as one of the major sources of cannabis worldwide. In 2020, its government passed a legislation enabling the cultivation of local medicinal cannabis. This first study following the legislative change examines the overlapping use of cannabis for recreational/medicinal purposes and characteristics of the distinct cannabis user types.

METHODS

A total of 1230 young adults (18-24 years) filled an anonymous online survey in early 2020.

RESULTS

Young adults in the sample were distributed as follows: 33% 18-20 years; 60% males; 94% Lebanese; 75% students; and 89% living with family. The older young adults (21-24), males, those employed, living with non-family members, and who perceived themselves as being a little/lot richer than most were statistically significantly more present in the cannabis user subtypes (recreational only or recreational/medicinal) than non-cannabis users. When dual recreational/medicinal users are compared to recreational users only, the latter seemed to have a more conservative profile of behaviours, attitudes, and perceptions and acts of harm. The prevalence ratio comparing the prevalence of users supporting consuming cannabis "once or twice" in dual motive users vs. recreational users only was 1.13 for "once or twice", 1.25 for "occasionally", 1.64 for "regularly", and 2.4 for "daily". Any other illicit drug use was reported by 1% of the non-cannabis users, 36% of the recreational users only, and 58% of the recreational/medicinal users (p-value < 0.01). Similarly, any prescription drug use was reported by 3% of the non-cannabis users, 16% of the recreational users only, and 28% of both recreational/medicinal users (p-value < 0.01).

CONCLUSION

The interface between recreational and medicinal cannabis use is complex. Dual motive users may warrant special attention as a subpopulation of cannabis users. This is relevant to contexts experiencing medicinal cannabis legislation changes, such as Lebanon, as policymakers and implementers should be sensitized to the emerging evidence for more data-informed policy changes.

Selective Cytotoxicity of Medical Cannabis (Cannabis sativa L.) Extracts Across the Whole Vegetation Cycle Under Various Hydroponic and Nutritional Treatments

Introduction: The use of Cannabis sativa L. in health care requires stringent care for the optimal production of the bioactive compounds. However, plant phenotypes and the content of secondary metabolites, such as phytocannabinoids, are strongly influenced by external factors, such as nutrient availability. It has been shown that phytocannabinoids can exhibit selective cytotoxicity against various cancer cell lines while protecting healthy tissue from apoptosis. Research Aim: This study aimed to clarify the cytotoxic effect of cannabis extracts on colorectal cell lines by identifying the main active compounds and determining their abundance and activity across all developmental stages of medical cannabis plants cultivated under hydroponic conditions. Materials and Methods: Dimethyl sulfoxide extracts of medical cannabis plants bearing the genotype classified as chemotype I were analyzed by high-performance liquid chromatography, and their cytotoxic activity was determined by measuring cell viability by methylthiazolyldiphenyl-tetrazolium bromide assay on the human colon cancer cell lines, Caco-2 and HT-29, and the normal human epithelial cell line, CCD 841 CoN. Results: The most abundant phytocannabinoid in cannabis extracts was tetrahydrocannabinolic acid (THCA). Its maximum concentrations were reached from the 7th to the 13th plant vegetation week, depending on the nutritional cycle and treatment. Almost all extracts were cytotoxic to the human colorectal cancer (CRC) cell line HT-29 at lower concentrations than the other cell lines. The phytocannabinoids that most affected the cytotoxicity of individual extracts on HT-29 were cannabigerol, Δ9-tetrahydrocannabinol, cannabidiol, cannabigerolic acid, and THCA. The tested model showed almost 70% influence of these cannabinoids. However, THCA alone influenced the cytotoxicity of individual extracts by nearly 65%. Conclusions: Phytocannabinoid extracts from plants of the THCA-dominant chemotype interacted synergistically and showed selective cytotoxicity against the CRC cell line, HT-29. This positive extract response indicates possible therapeutic value.

The Effect of Route of Administration and Vehicle on the Pharmacokinetics of THC and CBD in Adult, Neonate, and Breastfed Sprague-Dawley Rats

Introduction: Basic pharmacokinetic (PK) and pharmacodynamic models of the phytocannabinoids Δ-9-tetrahydrocannabinol (THC) and cannabidiol (CBD) are critical for developing translational models of exposure and toxicity. The neonatal period is a particularly important time to study the effects of cannabinoids, yet there are few studies of cannabinoid PKs by different routes such as direct injection or breast milk ingestion. To study this question, we have developed a translationally relevant rodent model of perinatal cannabinoid administration by measuring plasma levels of THC and CBD after different routes and preparations of these drugs. Materials and Methods: Adult animals and pups were injected with THC or CBD either intraperitoneally or subcutaneously, and plasma was analyzed by liquid chromatography-tandem mass spectrometry to measure cannabinoid levels collected at specified intervals. We also tested the effect of preparation of the drug using an oil-based vehicle (sesame oil) and an aqueous vehicle (Tween). Finally, we measured the plasma levels of cannabinoids in neonatal pups that were transmitted through breast milk after intraperitoneal injection to nursing dams. Results: We observed differences in the PK profiles of cannabinoids in adults and neonatal pups that were dependent on the route of administration and type of vehicle. Cannabinoids prepared in aqueous vehicle, injected intraperitoneally, resulted in a high peak in plasma concentration, which rapidly decreased. In contrast, subcutaneous injections using sesame oil as a vehicle resulted in a slow rise and low plateau in plasma concentration. Intraperitoneal injections with sesame oil as a vehicle resulted in a slower rise compared with aqueous vehicle, but an earlier and higher peak compared with subcutaneous injection. Finally, the levels of THC and CBD that were similar to direct subcutaneous injections were measured in the plasma of pups nursing from intraperitoneally injected dams. Conclusions: The route of administration and the preparation of the drug have important and significant effects on the PK profiles of THC and CBD in rats. These results can be used to create different clinically relevant exposure paradigms in pups and adults, such as short high-dose exposure or a low-chronic exposure, each of which might have significant and varying effects on development.

A Pragmatic, Person-Centered View of Cannabis in the United States: Pursuing Care That Transcends Beliefs

BACKGROUND

Rates of cannabis use are increasing in the United States, likely as a result of changes in societal attitudes and expanding legalization. Although many patients report wanting to discuss the risks and benefits of cannabis use with their clinical providers, many providers hold conflicting beliefs regarding cannabis use and often do not engage patients in discussion about cannabis. This dilemma is underscored by the limitations imposed on cannabis related research, and lack of empirically based best-practice guidelines for clinicians when addressing cannabis use with patients.

OBJECTIVES

We aimed to briefly summarize clinician and patient attitudes toward cannabis use and review current clinical guidelines and provide suggestions to assist health care providers and clinicians in increasing their comfort and skill in discussing cannabis use with patients.

METHODS

A narrative review on attitudes toward cannabis use and clinical guidelines was performed to summarize the literature and provide evidence-based recommendations.

RESULTS

Attitudes toward cannabis use have been shaped by personal and political factors and contribute to clinician hesitance in speaking with patients about the topic. Administrative barriers have hindered the development of clearer public health guidelines that might enable the dissemination of evidence-based information on the health effects of cannabis use and might ultimately lead to better health outcomes.

CONCLUSION

Not discussing cannabis use with patients may be a crucial missed opportunity for harm reduction. In the absence of empirically supported best-practice guidelines, a person-centered approach can facilitate conversations on the harms and benefits of cannabis use.

Post-retirement enlightenment syndrome: Worthy of investigation

Post-Retirement Enlightenment Syndrome is a term used by some in illicit drug policy to reflect the experience of having politicians "come out" in favour of drug policy reform only after retirement. To date, the phenomenon has not been examined in any systematic manner. While discussions of the phenomenon on social media tend to be playful, they nevertheless express real frustration with the reluctance of privately supportive sitting politicians and policing officials to speak out in favour of non-punitive and/or harm reduction-oriented policies. In this commentary, we give an overview of the phenomenon of Post-Retirement Enlightenment Syndrome. We argue that these instances of sitting officials speaking out publicly in favour of drug policy reform, as well as instances in which such apparent "enlightenment" is not publicly expressed until after retirement, are potentially highly fruitful areas for investigation. Public positions on drug policy are invariably contoured by conditions of political possibility. We raise the call for both an unpacking and examination of the structural and relational aspects of "political will" and "political courage". Sitting and retired politicians each have a role in the drug policy landscape, whether as lawmakers or as high-profile and often respected commentators. This commentary argues that a more nuanced understanding of the conditions that may support or hinder the expression of public support for drug policy reform by political office bearers, whether sitting or former, has implications for advocates and researchers invested in policy change.

Impacts of recreational cannabis legalization on use and harms: A narrative review of sex/gender differences

Legalization of cannabis use for non-medical (recreational) purposes is changing the global cannabis landscape. As attitudes toward cannabis use become more positive and prevalence of use increases in complex ways, concerns emerge about the potential for increased cannabis-attributable harms. Understanding the who, why, and when of this likely increase in cannabis-attributable harms is thus an important public health priority. Both sex and gender contribute to variability in the use, effects, and harms of cannabis and thus sex/gender considerations are important when evaluating the impacts of cannabis legalization. The goal of this narrative review is to broadly discuss sex/gender differences in attitudes toward and prevalence of cannabis use, whether there are sex/gender differences in the impacts of cannabis legalization, and why these sex/gender differences might exist. One of our strongest conclusions is that men have always been more likely to use cannabis than women, yet the sex/gender gap in prevalence of cannabis use has narrowed over time, and this might be partly due to cannabis legalization. The existing evidence suggests that there have also been sex/gender differences in the impacts of legalization on cannabis-attributable harms such as cannabis-involved motor vehicle collisions and hospitalizations, though these results are more variable. The body of literature reviewed has focused almost exclusively on samples of cisgender research participants, and thus future research should encourage inclusion of transgender and gender-diverse participants. More consideration of sex- and gender-based analysis in research evaluating long-term impacts of cannabis legalization is a clear research priority.

Trends in cannabis use intention around the period of cannabis legalisation in Australia: An age-period-cohort model

INTRODUCTION

This study examines age, time period and birth cohort trends in cannabis use intention and weekly use in Australia over a period in which medicinal cannabis was legalised.

METHODS

Hierarchical age-period-cohort models were used to analyse the National Drug Strategy Household Survey between 2001 and 2019, including 158,395 participants aged 18-79 years.

RESULTS

The hierarchical age-period-cohort model demonstrated a decrease in likelihood of intending to try cannabis as age increases. Similar age effects were found in intending to use cannabis as often or less often. There was broad-based shift in attitudes for people wanting to try cannabis (2007: b = -0.51 [-0.82, -0.21]; 2019: b = 0.68 [0.38, 0.98]) or use cannabis more often (2007: b = -0.15 [-0.50, 0.20]; 2019: b = 0.83 [0.49, 1.18]). The population trend of weekly cannabis use decreased in the earlier periods but increased since 2013 (b = -0.13 [-0.25, -0.02] vs 2019: b = 0.06 [-0.09, 0.20]). This suggests that legalisation would increase uptake of cannabis and consumption among current consumers. There were distinctive inter-generation variations: people born between 1950s and 1960s had more liberal views towards cannabis use than people born before or after (p < 0.05). There were indications that young people born in the 1990 s are catching up with the baby boomers in using cannabis more often if it was legal.

DISCUSSION AND CONCLUSIONS

There has been a population-based shift in Australia in favourable attitudes towards cannabis use, more so among those born in the 1950s to 1960s than other generations. Liberal attitudes and more frequent cannabis use may put certain cohorts at higher risks of cannabis dependence and related harms.

The impact of education on attitudes toward medical cannabis

Objective

This research explores the impact of patient education on reducing historical and current stigma.

Methods

Participants were recruited through social media, parenting with community organizations, and snowball sampling. A pretest posttest method was utilized. Participants viewed five balanced educational videos about medicinal cannabis. Attitudes toward medical cannabis were measured with a modified version of the medical component of the Recreational and Medical Cannabis Attitudes Scale (RMCAS). In total, 111 participants completed all requirements of the study.

Results

Results of a Wilcoxon Sign Rank Test demonstrated a significant increase in the modified medical component of the RMCAS (1.18, p = 0.029).

Conclusion

Health education is an effective intervention to reduce stigma associated with medical cannabis. Future health policies must take a balanced, education-focused, and proactive stance in reducing barriers to care that exist due to the negative stigma associated with cannabis use.Innovation: Historically, patient education has focused on areas such as tobacco, automobile safety, vaccinations, obesity, and the like. This research applied patient education to the area of medical cannabis to improve attitudes toward it and improve patient access.

Demographic factors that impact attitudes toward medical cannabis

Objective

This study aims to identify pertinent demographic characteristics that influence attitudes toward medical cannabis.

Methods

Survey respondents were recruited through social media posts, partnering with community organizations, and snowball sampling. Attitudes were measured with a modified version of the medical component of the Recreational and Medical Cannabis Attitudes Scale (MMCAS). Data were analyzed using a one-way ANOVA or one-way Welch ANOVA to determine differences within demographic characteristics. A Tukey-Kramer, or Games-Howell, post-hoc analysis was conducted to determine specific groups within the independent variables that significantly impacted medical cannabis attitudes.

Results

A total of 645 participants completed the survey. Significant variation in MMCAS was noted between groups based on race, political party affiliation, political view, religion, state legal status, and past/current cannabis use. There were no significant variations noted in MMCAS for apolitical factors.

Conclusion

Political, religious, and legal demographic factors impact attitudes toward medical cannabis.

Innovation

The use of health education targeted at the groups of people who continue to harbor antiquated attitudes toward medical cannabis will help to improve patient access and, thus, patient outcomes. Cannabis advocates can innovatively apply health education efforts to groups of people who are aligned with the demographic factors identified in this current work.

Ghana's preparedness to exploit the medicinal value of industrial hemp

BACKGROUND

Interest in industrial hemp is increasing steadily, as can be seen by the growing number of countries that have either decriminalized industrial hemp or are contemplating its decriminalization. In line with this trend, Ghana recently decriminalized the cultivation of industrial hemp (the cannabis variety with low Δ⁹-tetrahydrocannabinol (THC) and high cannabidiol (CBD) content), resulting in the need for research into its benefits to Ghanaians. This article examines cannabis (including industrial hemp) production, facilities for industrial hemp exploitation, and the potential benefits of industrial hemp in Ghana.

MAIN BODY

Indigenous cannabis strains in Ghana have high THC to CBD ratios suggesting the need for the government to purchase foreign hemp seeds, considering that the alternative will require significant research into decreasing the THC to CBD ratio of indigenous cannabis strains. Furthermore, there are several facilities within the country that could be leveraged for the production of medicinal hemp-based drugs, as well as the existence of a number of possible regulatory bodies in the country, suggesting the need for less capital. Research has also shown the potential for treatment of some medical conditions prevalent among Ghanaians using medicinal hemp-based products. These reasons suggest that the most feasible option may be for the government to invest in medicinal hemp.

CONCLUSION

Considering the challenges associated with the development of other hemp-based products, the availability of resources in the country for exploitation of medicinal hemp, and the potential benefits of hemp-based drugs to Ghanaians, investing in medicinal hemp may be the best option for the government of Ghana.

Estimating the Prevalence of Substance Use Disorders in the US Using the Benchmark Multiplier Method

Importance

Prevalence estimates of substance use disorders in the US rely on general population surveys. However, major population groups, such as homeless individuals and institutionalized individuals, are not captured by these surveys, and participants may underreport substance use.

Objective

To estimate the prevalence of substance use disorders in the US.

Design, Setting, and Participants

The benchmark multiplier method was used to estimate the prevalence of alcohol, cannabis, opioid, and stimulant use disorders based on data from the Transformed Medicaid Statistical Information System (T-MSIS) (the benchmark) and the National Survey on Drug Use and Health (NSDUH) (the multiplier) for 2018 and 2019. T-MSIS collects administrative data on Medicaid beneficiaries 12 years and older with full or comprehensive benefits. NSDUH is a nationally representative annual cross-sectional survey of people 12 years and older. Data were analyzed from February to June 2022.

Main Outcomes and Measures

Prevalence of substance use disorders was estimated using the benchmark multiplier method based on T-MSIS and NSDUH data. Confidence intervals for the multiplier method estimates were computed using Monte Carlo simulations. Sensitivity of prevalence estimates to variations in multiplier values was assessed.

Results

This study included Medicaid beneficiaries 12 years and older accessing treatment services in the past year with diagnoses of alcohol (n = 1 017 308 in 2018; n = 1 041 357 in 2019), cannabis (n = 643 737; n = 644 780), opioid (n = 1 406 455; n = 1 575 219), and stimulant (n = 610 858; n = 657 305) use disorders and NSDUH participants with 12-month DSM-IV alcohol (n = 3390 in 2018; n = 3363 in 2019), cannabis (n = 1426; n = 1604), opioid (n = 448; n = 369), and stimulant (n = 545; n = 559) use disorders. The benchmark multiplier prevalence estimates were higher than NSDUH estimates for every type of substance use disorder in both years and in the combined 2018 to 2019 sample: 20.27% (95% CI, 17.04-24.71) vs 5.34% (95% CI, 5.10-5.58), respectively, for alcohol; 7.57% (95% CI, 5.96-9.93) vs 1.68% (95% CI, 1.59-1.79) for cannabis; 3.46% (95% CI, 2.97-4.12) vs 0.68% (0.60-0.78) for opioid; and 1.91% (95% CI, 1.63-2.30) vs 0.85% (95% CI, 0.75-0.96) for stimulant use disorders. In sensitivity analyses, the differences between the benchmark multiplier method and NSDUH estimates persisted over a wide range of potential multiplier values.

Conclusions and Relevance

The findings in this study reflect a higher national prevalence of substance use disorders than that represented by NSDUH estimates, suggesting a greater burden of these conditions in the US.

Impact of cannabis knowledge and attitudes on real-world practice

BACKGROUND

Increased cannabis consumption worldwide challenges allergists because of an upsurge in cannabis allergy and need to discuss cannabis with patients.

OBJECTIVE

To determine the knowledge, attitudes, and practices regarding cannabis among allergists and their approach to recognizing and diagnosing suspected cannabis allergy.

METHODS

The International Allergist Canna Knowledge, Attitudes, and Practices Survey was completed by members from 3 International Allergy Societies. Survey questions included the following: 13 on cannabis attitudes, 7 on cannabis knowledge, and 4 on real-world allergy practices. Knowledge level was dichotomized and Statistical Package for the Social Sciences TwoStep Cluster Analysis grouped participants by attitudes. Multivariate analysis determined the relationship of knowledge and attitude to practice delivery.

RESULTS

Of 570 eligible surveys started, 445 (78.1%) were completed. Participants were 49.7% of female sex, 65.9% aged 24 to 56 years, approximately 70% in practice for more than or equal to 10 years, and 29.2% practicing in an area where cannabis use is illegal. Of the respondents, 43.1% reported consulting on patients with suspected cannabis allergy and 54.7% had undertaken skin prick testing, in vitro cannabis testing, or both. Statistically significant differences were found between the 3 societies for most variables analyzed. Analysis of attitudes revealed 3 clusters named Traditional, Progressive, and Unsure. Those with more progressive attitudes toward cannabis and who had more knowledge were more comfortable speaking to patients about cannabis and more often asked patients on how often and how they used cannabis (all P < .001).

CONCLUSION

Varying knowledge and attitudes toward cannabis affecting comfort communicating with patients about cannabis were found in members of 3 allergy societies supporting the need for more cannabis research and education.

Increasing prevalence of illicit drug use among employees at Swedish workplaces over a 25-year period

Background

Reports indicate that the proportion of adults using drugs of abuse has been increasing in recent years in Europe. Although there are various indicators of increased drug use in Sweden over time, few studies could demonstrate an increase in the proportion of adults using drugs. To investigate changes in drug use prevalence over time, drug testing at the workplace has been used for a 25-year period.

Methods

The urine samples of employees sent by occupational health services from all over Sweden during a 25-year period were analyzed. The analyzing capacity increased over time (from 3411 in 1994 to 60 315 samples analyzed in 2019), and the majority of the samples was analyzed for the following drugs: cannabis (tetrahydrocannabinol), amphetamine, opiates, cocaine, and benzodiazepines.

Results

There was an overall increase in the proportion of samples that tested positive for illicit drugs over a 25-year period. This increase seemed to take place step-wise, with phases of linear increases and plateaus that over time became shorter. About 1.3% of samples tested positive for drugs in 1994, whereas 5.6% tested positive in 2019. Since 2007, the rate of positive samples has increased for cannabis and decreased for benzodiazepines. Although the rate of samples tested positive for opiates had remained relatively stable over the last 20 years, this rate had increased for amphetamine and cocaine between 2013 and 2019.

Conclusion

The results indicate that the use of illicit drugs among employees at Swedish workplaces has increased during a 25-year period.

Differences in Attitudes Toward Medical Cannabis With Humanized Patient Scenarios

Introduction

Attitudes toward medical cannabis are shaped by a number of factors, such as religion, previous use, and political affiliation. Individuals with less supportive beliefs toward cannabis, in general, may be more open to its therapeutic applications in a humanized patient scenario (PS).

Methods

A modified medical cannabis attitude scale was used to measure participants' attitudes toward medical cannabis. Two humanized patient scenarios were presented to the participants, and their level of agreement with the patient having access to medical cannabis was measured. After the scales were standardized, a Wilcoxon signed-rank test (WSR) was utilized to determine whether a difference between medical cannabis attitudes and approval of medical cannabis use in the humanized PS exists.

Results

A total of 645 participants completed the full survey and were included in the data analysis. Most participants were supportive of the patients in the humanized scenarios having access to medical cannabis; 76.1% and 75.7% of respondents, in each of the scenarios, selected the highest level of approval. There was a significantly higher approval for medical cannabis with the PS than attitudes toward medical cannabis in general (Z=-17.415, p<0.0005).

Conclusion

Individuals were more supportive of patient access to medical cannabis when exposed to humanized PS than their general attitudes toward medical cannabis indicated. Applying the results of this current research, a viable plan to reduce the stigma surrounding cannabis is to use patient testimonials in public-facing advocacy efforts regarding medical cannabis.

Multimodal Correlates of Cannabis Use among U.S. Veterans with Bipolar Disorder: An Integrated Study of Clinical, Cognitive, and Functional Outcomes

Objective: Cannabis use (CU) is common among persons with bipolar disorder (BD). Evidence suggests that CU is associated with poorer outcomes among persons with BD; however, these findings remain inconsistent. The present exploratory study aims to examine clinical, functional, and cognitive correlates of CU among persons with BD. Methods: U.S. veterans with BD type I who participated in a large-scale, nationwide study were categorized into four groups: current CU, past CU, past other drug use, and no drug use. Bivariate analyses, univariate analyses of covariance, and Levene's Test for Equality of Variance were used to compare groups on clinical, cognitive, and functional measures. Results: Of 254 (84.6% male) veterans with BD type I included in the analyses, 13 (5.1%) had current CU, 37 (14.5%) past CU, 77 (30.3%) past other drug use, and 127 (50%) reported no drug use. BD with CU was associated with post-traumatic stress disorder (PTSD) and experiencing lifetime suicidal ideation. Notably, current CU was associated with higher working memory performance, compared to both past CU and no drug use. Likewise, current CU was associated with higher functional capacity, compared to past CU as well as no drug use. Conclusions: These findings contribute to the growing literature on the complex effects of cannabis on BD. As the commercialization and legalization of cannabis increases, further research in this area is warranted to quantify posed risks to this population, and thereby guide clinical decision-making.

Attitudes and beliefs of medicine and social work students about medical cannabis use for epilepsy

The current study sought: (i) to explore whether health profession students possess formal medical cannabis (MC) education, feel prepared to answer questions about MC, and perceive it as an effective therapy for epilepsy; (ii) to assess students' attitudes and beliefs about MC use; and (iii) to explore the associations between students' background characteristics, MC-related attitudes and beliefs regarding its effectiveness for epilepsy. A sample of 310 students (141 from medicine and 169 from social work) voluntarily participated in the anonymous online survey. The vast majority (92.5%) indicated they had no formal education about MC, and only 11.2 % reported being prepared to answer clients' MC-related questions. Participants reported favorable beliefs about MC benefits, the need for training, and recreational marijuana use legalization. Less supportive attitudes were reported regarding MC risks. Prior cannabis use (e.g., self-use, friends, or family) and individuals from a secular background were associated with more positive beliefs about MC benefits and its legalization for recreational purposes. Prior recreational cannabis use [OR=1.541] and having friends who recreationally use the substance [OR=1.891] were associated with the belief that MC is an effective therapy for epilepsy. These findings indicate an urgent need for students' MC education to provide future physicians and social workers with MC-related capacities. Development of curricula and training programs in Israel are encouraged.

A Systematic Review of Trends in US Attitudes toward Cannabis Legalization

METHODS

A systematic search was conducted for publications in PubMed, EMBASE, and PsycINFO up to October 2019. Six studies with a regionally or nationally representative adult US-based populations were included. A secondary analysis was conducted using data from the National Survey of Drug Use and Health. Hierarchical age-period-cohort analysis assessed the trends in perceived harmfulness and availability of cannabis between 1996 and 2018. Ecological comparisons were made between these perceptions and support for cannabis legalization over time.

RESULTS

A steep growth in support for cannabis legalization began in the 1990s and continued to grow in a relatively linear manner. Most people developed more liberal views, with no evidence that changes within any one sociodemographic group was disproportionately responsible for the overall attitudinal change. Increases in the proportion of people who use cannabis, non-religious population and political liberalism may partially explain the increased support for legalization. The decline in perceived harmfulness of cannabis, as reflected in the media, may have contributed to the increased support for legalization. However, perceptions of the availability of cannabis remained stable despite significant relaxations in cannabis regulations.

CONCLUSIONS

The US population has become more accepting of cannabis legalization. The attitudinal change is related to changes in the perceived risks and benefits of cannabis use, influenced by broader political and cultural changes over the study period.

Drug Legalization, Elite Support, and Government Effectiveness in Latin America

In Latin America, the legalization of drugs—where it occurred—has been driven mainly by elites, although much attention has been placed on public opinion. Considering that efforts toward legalization have been top-down, analysis should concentrate on opinions of the governing elites. To undertake such an analysis, we draw on data from surveys conducted in 18 Latin American parliaments (2012–2018), and we examine elite perspectives on the legalization of all drugs. Results from a Bayesian hierarchical logistic analysis show that in countries where the government is less effective, and where public health problems persist, legislators are less likely to support legalization. We argue that this is due to a lack of trust by MPs in legalization as a solution to trafficking. Wherever those concerned with drug trafficking see the current government as problematic, they will be less likely to support so challenging and complex a policy as drug legalization.

America's Liberal Social Climate and Trends: Change in 283 General Social Survey Variables between and within US Birth Cohorts, 1972-2018

The late James A. Davis characterized American public opinion in the Reagan era as "conservative weather" amidst a liberalizing "climate." By climate, he meant differences between cohorts, while the weather referred to trends within cohorts. Thirty years later, the public opinion climate continues to get more liberal, as each successive cohort continues to be more liberal, on balance, than the ones that came before them. Recent weather complements that by being quite liberal, too. Specifically, 62 percent of variables analyzed were more liberal in recent birth cohorts than they were in the oldest ones, but just 5 percent were more conservative (some did not differ among cohorts, and some were neither liberal nor conservative). Within cohorts, recent measurements were more liberal than early measurements for 51 percent of the variables and more conservative for 11 percent.

Age-related trends in cannabis use in Australia. Findings from a series of large nationally representative surveys

AIM

We examine age-related trends in past-year cannabis use in a series of nationally representative surveys in Australia.

METHODS

We analysed data from the largest nationally representative survey in Australia collected between 2001 and 2019 (National Drug Strategy Household Survey [NDSHS]; N = 157,151). Prevalence of past-year daily/occasional (non-daily)/non-use of cannabis use were estimated using weighted multinomial logistic regression and predicted marginal probabilities. Difference-in-difference analysis was used to examine if trends of cannabis use across age groups were different.

RESULTS

The youngest age group (14-17 s) witnessed the largest increase in past-year abstinence rate from 79% to 92% from 2001 to 2019 (p < .003); the increase in abstinent rate among the 18-24 and 25-39 were relatively moderate (from 68 to 76% and from 81% to 84% respectively; p < .003). The abstinent rate among the 40-54 s and 55-74 s decreased significantly from 93% to 90% and from 99% to 95% respectively (p < .003). There were similar diverging trends in occasional and daily cannabis use, with decreases in both patterns of use observed among the younger age group (14-17 s and 18-25 s) but increases among the older age group (40-54 s and 55-74 s).

CONCLUSION

There is a diverging trend in cannabis use among younger and older age groups in Australia between 2001 and 2019. Cannabis use substantially decreased among the youngest age group (14-17 s) but modestly increased among older people (55-74 s).

Attitudes and beliefs about recreational cannabis legalization among cannabis-using young adults in Los Angeles: Impact on concurrent cannabis practices and problematic cannabis use

BACKGROUND

This study investigated differences in attitudes and beliefs about recreational cannabis legalization (RCL) among cannabis-using young adults comprised of medical cannabis patients (MCP) and non-patient users (NPU). We further investigated whether these variations are associated with concurrent cannabis practices and problematic use.

METHOD

Cannabis-using young adults (N = 301) were interviewed between 2017 and 2018 - after RCL and through the early months after storefront sales began. Latent class analysis empirically derived groups based on participants' attitudes/beliefs about the impact of RCL. Socio-demographic factors, patient status, medicinal and/or recreational use, and social norms differentiated latent class memberships, while concurrent cannabis practices and problematic use served as distal outcomes. The manual Bolck, Croon, and Hagenaars (BCH) three-step process modeled all covariates and distal outcomes simultaneously in the final LCA solution.

RESULTS

Three patterns emerged: Impacted (RCL had broad impact on attitudes/beliefs) (n = 113), Partially-Impacted (RCL had some impact on attitudes/beliefs) (n = 131) and Neutral (RCL had no/limited impact) (n = 57). MCP were more likely to be Neutral than Partially-Impacted users while those who reported recreational cannabis use were more likely to be Impacted than Neutral users. Class membership predicted cannabis practices and problematic use with Impacted individuals reporting the greatest recent days of use, number of hits per day, and highest scores in problematic cannabis use compared to Partially-Impacted and Neutral users.

CONCLUSION

Variability in attitudes/beliefs about RCL served as strong drivers of concurrent cannabis practices and problematic use. Findings provide an important baseline for tracking attitudes/beliefs' long-term health and substance use impact as retail cannabis sales evolve.

Public health impacts to date of the legalisation of medical and recreational cannabis use in the USA

The legality of cannabis use has been changing in a number of jurisdictions around the world. In the U.S., it has been legalised for medicinal and/or recreational uses in 34 jurisdictions and counting. This study leverages the decades-long experience of legalisation in the U.S. to provide an overview of the associated changes in public attitudes, cannabis markets and adverse health effects. We found a broad-based warming of public attitudes toward legalisation, potentially influenced by the increasingly positive portrayal of cannabis in media and declines in cannabis risk perceptions. Potency of cannabis products increased significantly while prices fell sharply. Although adults were less responsive to price changes than adolescents, adults who use cannabis regularly were sensitive to prices, with an estimated 10% price reduction leading to about 2.5% increase in the rate of use. Overall, past-year cannabis use has increased in adults since 2002, and adults over 26 years old who resided in states with medicinal cannabis laws were more likely to have used cannabis in the past 30 days, to have used daily, and to have higher rates of cannabis use disorders than adults who resided in states without legalised medicinal cannabis. Traffic fatalities involving cannabis temporarily increased in some states post-legalisation, and there were more presentations to medical services related to chronic regular cannabis use. There is suggestive evidence that adverse health consequences have increased among people who use cannabis regularly since legalisation. More robust research is needed to determine whether these effects of legalisation are temporary or long-term.

Cannabis use and cannabis use disorder

Cannabis use disorder (CUD) is an underappreciated risk of using cannabis that affects ~10% of the 193 million cannabis users worldwide. The individual and public health burdens are less than those of other forms of drug use, but CUD accounts for a substantial proportion of persons seeking treatment for drug use disorders owing to the high global prevalence of cannabis use. Cognitive behavioural therapy, motivational enhancement therapy and contingency management can substantially reduce cannabis use and cannabis-related problems, but enduring abstinence is not a common outcome. No pharmacotherapies have been approved for cannabis use or CUD, although a number of drug classes (such as cannabinoid agonists) have shown promise and require more rigorous evaluation. Treatment of cannabis use and CUD is often complicated by comorbid mental health and other substance use disorders. The legalization of non-medical cannabis use in some high-income countries may increase the prevalence of CUD by making more potent cannabis products more readily available at a lower price. States that legalize medical and non-medical cannabis use should inform users about the risks of CUD and provide information on how to obtain assistance if they develop cannabis-related mental and/or physical health problems.

Personal Correlates of Support for Medical and Recreational Cannabis Legalization in Australia

Introduction and Aims: Increasingly more Australians are in favor of legalizing medical and recreational cannabis use. This paper explored the personal characteristics of those who supported each of these policies in Australia. Design: Cross-sectional national survey. Methods: This study included 21,729 participants aged 18 years and above who responded to the 2016 National Drug Strategy Household Survey. Participants were provided the assurance of confidentiality for their participations. Logistic regression models were used to examine the relationships between personal characteristics and support for the legalization of medical and recreational cannabis. Results: Overall, 77 and 40% of participants supported the legalization of medical and recreational cannabis respectively. People of older age were more likely to support medical cannabis legalization while those who supported legalization of recreational cannabis use were more likely to be younger. Medical cannabis supporters were more likely to report chronic pain (OR = 1.44, 95% CI: 1.04, 2.00) while recreational cannabis supporters were more likely to suffer high level of psychological distress (OR = 1.28, 95% CI: 1.14, 1.43). Experience with cannabis use was strongly associated with supportive attitudes, with recent cannabis users almost 14 times (OR = 14.13, 95% CI: 5.37, 37.20) and 34 times (OR = 33.74, 95% CI: 24.22, 47.01) more likely to support the legalization of medical and recreational cannabis use, respectively. Discussion and Conclusions: The majority of Australians approve the legalization of cannabis for medicinal purposes but most remain cautious about legalizing recreational cannabis use. The sociodemographic and clinical profile of supporters of medical and recreational legalization suggests a potential interaction of self-interests and beliefs about the harms of cannabis use.

The effect of public opinion and politics on attitudes towards pill testing: Results from the 2019 Australian Election Study

INTRODUCTION AND AIMS

Following several deaths due to drug overdoses at music festivals in Australia, pill testing (or drug checking) has been proposed as a means of reducing the risk to young people. However, pill testing is a politically controversial policy in Australia. This paper examines the political dimension to the debate, its relationship with other social issues and how it divides party supporters.

DESIGN AND METHODS

The data come from the 2019 Australian Election Study survey-a large (n = 2179), nationally weighted representative probability survey conducted immediately after the federal election. Bivariate and multivariate analyses are used to identify the social groups, attitudes and vote preferences most associated with public views about pill testing.

RESULTS

Almost two-thirds of the public support pill testing at music festivals. The young and those who do not attend church are most likely to express support. Supporters of other liberal social opinions, such as the legalisation of marijuana, are also strongly supportive of pill testing. Those who vote for one of the two main conservative parties are less likely to support pill testing.

DISCUSSION AND CONCLUSIONS

While a majority of the public support pill testing, beyond the Australian Capital Territory this has not translated into policy in other jurisdictions. The results show that there is a high level of political polarisation surrounding opinions among both voters and political elites. This issue must be addressed if the policy is to be advanced as part of an overall harm reduction approach to drug use.

Higher and Higher? Drug and Alcohol Use and Misuse among HIV-Vulnerable Men, Trans Men, and Trans Women Who Have Sex with Men in the United States

BACKGROUND

Substance use (SU) and misuse are disproportionately more common among sexual and gender minority (SGM) individuals compared to their heterosexual peers. Yet, little is known about regional and demographic differences in use and misuse among SGM. In this study, we investigated regional and demographic differences in SU and misuse in a U.S. national, internet-based cohort (n = 6,280) of men and trans persons who have sex with men. Methods: Data collected included the WHO ASSIST (substance) and AUDIT (alcohol) SU scales to estimate recent (≤ 3 months) non-problematic use (≤ 3 ASSIST, ≤ 10 AUDIT) and misuse (≥4 ASSIST, ≥11 AUDIT). We used bivariate and multivariable logistic models to examine demographic and regional factors associated with SU and misuse. Results: Participants reported using alcohol (85.6%), cannabis (53.9%), and inhalants (39.1%) in the past three months. More than one-third self-reported misuse of cannabis, Gamma-Hydroxybutyrate (GHB), inhalants, methamphetamines, and prescription sedatives. We observed regional differences in substance use for cannabis (Southeast aOR = 0.76, 95% CI: 0.63-0.93; West aOR = 1.27, 95% CI: 1.02-1.59, ref. Northeast) and prescription Stimulants (Midwest aOR = 1.39, 95% CI: 1.00-1.93), as well as for cannabis misuse (Southeast aOR = 0.83, 95% CI: 0.69-0.99). We also observed significant associations between socioeconomic factors with use and misuse. Conclusions: Findings suggest geographic differences in misuse of certain substances among men and trans persons who have sex with men in the US, and that socio-economic factors, also play a key role in indicating risk.

The costs and benefits of cannabis control policies

As is the case for most drugs, cannabis use has costs and benefits, and so do the policies that attempt to minimize the first and maximize the second. This article summarizes what we know about the harmful effects of recreational cannabis use and the benefits of medical cannabis use under the policy of prohibition that prevailed in developed countries until 2012. It outlines three broad ways in which cannabis prohibition may be relaxed, namely, the depenalization of personal possession and use, the legalization of medical use, and the legalization of adult recreational use. It reviews evidence to date on the impacts of each of these forms of liberalization on the costs and benefits of cannabis use. It makes some plausible conjectures about the future impacts of the commercialization of cannabis using experience from the commercialization of the alcohol, tobacco, and gambling industries. Cannabis policy entails unavoidable trade-offs between competing social values in the face of considerable uncertainty about the effects that more liberal cannabis policies will have on cannabis use and its consequences for better or worse.
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Control of Recreational Cannabis in a New Zealand University Sample: Perceptions of Informal and Formal Controls

An increasing number of countries have, or are moving towards, reforming cannabis policies. New Zealand is also moving in this direction and the government will hold a referendum on the legalization of recreational cannabis in September 2020. To inform imminent public and political discussions it is important to understand how current cannabis use is controlled. Research suggests that cannabis law has been ineffective in NZ. Internationally, informal controls, rather than the law, have been found to shape cannabis use by creating a threshold for normalization, but the attitudes shaping this threshold are unknown. This study aimed to examine drug acceptability attitudes, specifically students' attitudes towards the illegal use of cannabis and their attitudes towards peers who abstain, sometimes use, or are heavy users of cannabis, to identify the factors that control cannabis use. Using a mixed methods approach, university students recruited their peers (N = 535) to complete a pen and paper survey investigating perceptions towards 3 cannabis user prototypes (abstainers, moderate users, heavy users), concern for legality of cannabis use, and the integration of cannabis into the student culture (perceptions of peers' use, ease of acquisition, and availability). Perceptions of peers' lifetime and regular use were 82% and 38.5%, respectively. Participants rated cannabis as easy to acquire and likely to be available at a typical student social occasion. The majority stated that the law does not deter use (92.7%); participants perceived the law to be soft and that they are unlikely to get caught. Participants' descriptions of the 3 cannabis user prototypes revealed a threshold for normalization. For instance, abstaining was perceived to be associated with positive attributes (such as being studious), linked to being less sociable, and linked to being less likely to be judged. Moderate use of cannabis was perceived to be normal and sociable. Heavy use was perceived to be associated with having negative attributes, such as being addicted, unhealthy, and an underachiever, and negative drug labels. Our findings revealed that cannabis use is not controlled by the law, but by informal thresholds of control. Moderate cannabis use is accepted whereas heavy cannabis use is not. We extended research by identifying the attitudes shaping these thresholds, in particular that negative outcomes associated with heavy use deters the normalization of this behavior. We argue that policy must be informed by, and build on, these informal controls. The negative perceptions associated with heavy use also raise concerns regarding the well-being of heavy users, and coupled with the ineffectiveness of cannabis law, lend support towards a health model for regulating cannabis. Furthermore, insights into the negative perceptions associated with heavy use could inform health interventions on the types of concerns that will resonate with users.

Assessing the public health impacts of legalizing recreational cannabis use: the US experience

The sale of cannabis for adult recreational use has been made legal in nine US states since 2012, and nationally in Uruguay in 2013 and Canada in 2018. We review US research on the effects of legalization on cannabis use among adults and adolescents and on cannabis-related harms; the impact of legalizing adult recreational use on cannabis price, availability, potency and use; and regulatory policies that may increase or limit adverse effects of legalization. The legalization of recreational cannabis use in the US has substantially reduced the price of cannabis, increased its potency, and made cannabis more available to adult users. It appears to have increased the frequency of cannabis use among adults, but not so far among youth. It has also increased emergency department attendances and hospitalizations for some cannabis-related harms. The relatively modest effects on cannabis use to date probably reflect restrictions on the number and locations of retail cannabis outlets and the constraints on commercialization under a continued federal prohibition of cannabis. Future evaluations of legalization should monitor: cannabis sales volumes, prices and content of tetrahydrocannabinol; prevalence and frequency of cannabis use among adolescents and adults in household and high school surveys; car crash fatalities and injuries involving drivers who are cannabis-impaired; emergency department presentations related to cannabis; the demand for treatment of cannabis use disorders; and the prevalence of regular cannabis use among vulnerable young people in mental health services, schools and the criminal justice system. Governments that propose to legalize and regulate cannabis use need to fund research to monitor the impacts of these policy changes on public health, and take advantage of this research to develop ways of regulating can-nabis use that minimize adverse effects on public health.

Monitoring Perinatal Exposure to Cannabis and Synthetic Cannabinoids

PURPOSE

Drug use during pregnancy is a critical global challenge, capable of severe impacts on neonatal development. However, the consumption of cannabis and synthetic cannabinoids is on the rise in pregnant women. Obstetric complications with increased risks of miscarriage, fetal growth restriction, and brain development impairment have been associated with perinatal cannabis exposure, but data on synthetic cannabinoid use during pregnancy are limited.

METHODS

We reviewed studies that investigated the risks associated with cannabis and synthetic cannabinoid use and those that reported the concentrations of cannabinoids and synthetic cannabinoids in maternal (breast milk) and neonatal (placenta, umbilical cord, meconium, and hair) matrices during human pregnancy. A MEDLINE and EMBASE literature search to identify all relevant articles published in English from January 1998 to April 2019 was performed.

RESULTS

Cannabis use during pregnancy is associated with increased risks of adverse obstetrical outcomes, although neurobehavioral effects are still unclear. Analyses of cannabinoids in meconium are well documented, but further research on other unconventional matrices is needed. Adverse effects due to perinatal synthetic cannabinoid exposure are still unknown, and analytical data are scarce.

CONCLUSIONS

Awareness of the hazards of drug use during pregnancy should be improved to encourage health care providers to urge pregnant women to abstain from cannabis and, if cannabis-dependent, seek treatment. Moreover, substances used throughout pregnancy should be monitored as a deterrent to cannabis use, and potential cannabis-dependent women should be identified, so as to limit cannabis-fetal exposure during gestation, and provided appropriate treatment.

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.

Public health implications of legalising the production and sale of cannabis for medicinal and recreational use

We assess the current and describe possible future public health impacts of the legalisation of cannabis production, sale, and use in the Americas. First, we describe global patterns of cannabis use and their most probable adverse health effects. Second, we summarise evidence regarding the effectiveness of cannabinoids for medicinal use and describe approaches that have been used to regulate the use of medicinal cannabis and how these approaches might have affected medicinal and recreational use and harms (eg, road crashes). Third, we describe how jurisdictions that have legalised recreational use have regulated production and sale of cannabis. Fourth, we evaluate the effects of cannabis legalisation on cannabis use and harms and on the use of alcohol, tobacco, and other drugs. Fifth, we use alcohol and tobacco policy examples to identify possible long-term public health effects of cannabis legalisation. Finally, we outline policy approaches that could minimise harms to public health arising from the legalisation of a commercial cannabis industry.

A nationwide survey of pharmacy students' knowledge and perceptions regarding medical cannabis

OBJECTIVE

The primary objective of this study was to compare knowledge and perceptions of medical cannabis (MC) between pharmacy students who attended schools where MC was legal and illegal.

DESIGN

A nationwide anonymous survey regarding MC was distributed to pharmacy students. The survey consisted of the following sections: (1) demographics and personal factors, (2) knowledge assessment of indications and adverse effects of MC, and (3) perceptions assessment.

SETTING AND PARTICIPANTS

Equal numbers of pharmacy schools were selected and sent surveys based on geographical regions, private versus public universities, and the state's legal status of MC for first through fourth-year pharmacy students to complete.

OUTCOME MEASURES

Student knowledge of MC indications and adverse effects were treated as quizzes. Median percentage correct and whether students passed the quizzes (≥ 70%) were evaluated based on the state's legal status. Students' perceptions were similarly compared.

RESULTS

A total of 629 students accessed the survey. Most students who completed the survey attended pharmacy schools where MC was illegal (55%), were female (68%), and had personally tried cannabis (53%). Overall, 91% of students believed that MC should be legalized nationally. A low number of students correctly identify approved indications with 14.8% of students in states with MC legalization scoring greater than 70% compared with 15.9% of students in states without MC legalization (P = 0.748). Similar findings were seen in the side effects quiz with only 6.1% of students in states with legal MC scoring greater than 70% compared with 7.4% of students where MC is illegal (P = 0.569) There were minimal differences in students' perceptions of MC based on the states' legal status.

CONCLUSION

Our study continues to highlight that pharmacy students lack knowledge and preparation to counsel and educate on MC. With increasing state legalizations, pharmacy schools need to address this knowledge gap to ensure optimal patient care.