Half-baked--the retail promotion of marijuana edibles

Unintentional poisoning exposures: how does modeling the opening of child-resistant containers influence children's behaviors?

OBJECTIVE

Unintentional poisoning in the home is a risk for children. Over-the-counter medicinal products in child-resistant containers (CRC) are common causes of pediatric poisoning. The current study examined children's abilities to open three types of CRC mechanisms (twist, flip, and push) and corresponding control containers, comparing their ability to do so spontaneously and after explicit modeling. The study also examined if inhibitory control (IC) was associated with children's overall score for spontaneous openings.

METHOD

Children 5-8 years old were randomly assigned to one of three mechanism conditions (between-participants factor): twist, flip, and push, with each child experiencing both a risk and a control container (within-participants factor) having that mechanism. Children were first left alone with a container (measures: engagement with container, spontaneous opening) for up to 2 min and subsequently observed an adult explicitly model opening the container before the child was asked to do so (measure: opening after modeling).

RESULTS

Children were more engaged with and likely to spontaneously open control containers than CRCs, though some (4%-10%) also opened CRCs. After modeling, significantly more children opened each of the three types of CRCs, with nearly all children opening the push mechanism CRC. IC positively predicted children being more engaged with and spontaneously opening more containers.

CONCLUSIONS

Implications for improving pediatric poison prevention are discussed.

The Impact of Legalizing Recreational Cannabis on the Children of a Neighboring State

OBJECTIVES

In the United States, cannabis is legal for adult recreational use in 24 states and Washington, DC. Unintentional pediatric cannabis exposures have increased in many states following legalization.We evaluated the relationship between recreational cannabis legalization and the rates of unintentional pediatric exposures in a neighboring state that had not undergone legalization.

METHODS

We obtained cannabis exposure cases for children 0-12 years from the New Mexico Poison and Drug Information Center electronic database. Only deidentified patient data from closed-case exposure encounters were abstracted. Data were grouped as precommercial and postcommercial availability in neighboring Colorado, demarcated by January 2014. We coded cannabis products as edible, not edible, or unknown. For bivariable comparisons, we used odds ratios, risk ratio, χ2 test, and Wilcoxon rank sum test. We chose a type 1 error rate of 0.05 to determine significance.

RESULTS

There were 269 exposures over 24 years of calls. Following neighboring legalization, the median number of exposures per year increased from 4 (interquartile range 2, 5) to 24.5 (16.5, 34), the median age increased from 1.9 to 3.0 (P = 0.007), and the relative risk of the exposure involving edible products was double (relative risk = 2.0, 95% confidence interval = 1.6, 2.6). The severity of the exposures' medical effects also increased (P = 0.008).

CONCLUSIONS

The number, severity, and type of pediatric cannabis exposures in New Mexico changed after neighboring recreational cannabis legalization. States neighboring those undergoing cannabis legalization should be prepared to respond to increased acute exposures in children.

Regulatory Framework for Cannabis: A Position Paper From the American College of Physicians

Cannabis, also known as marijuana, is the dried flowers, stems, seeds, and leaves of the Cannabis sativa plant. It contains more than 100 compounds, including tetrahydrocannabinol, which has psychoactive effects. Federal law prohibits the possession, distribution, and use of cannabis outside limited research activities, but most states have legalized cannabis for medical or recreational use. However, research into the potential therapeutic and adverse health effects of cannabis has been limited, in part because of the drug's federal legal status. In this position paper, the American College of Physicians (ACP) calls for the decriminalization of possession of small amounts of cannabis for personal use and outlines a public health approach to controlling cannabis in jurisdictions where it is legal. ACP recommends the rigorous evaluation of the health effects and potential therapeutic uses of cannabis and cannabinoids as well as research into the effects of legalization on cannabis use. It also calls for evidence-based medical education related to cannabis and increased resources for treatment of cannabis use disorder.

Cannabis use among adolescents and young adults during the COVID-19 pandemic: A systematic review

Background

A systematic review of the literature was performed to summarize cannabis use among adolescents and young adults during the COVID-19 pandemic. Special focus was given to the prevalence of cannabis use during COVID-19, as well as factors that may explain changes in cannabis consumption patterns.

Methods

The protocol of this systematic review was registered. Articles from seven publication databases were searched in January 2022. The inclusion criteria for studies were as follows: 1) published in English; 2) study instruments needed to include items on COVID-19; 3) conducted after January 1st, 2020; 4) published in a peer-reviewed journal, dissertation, or thesis; 5) study population ≤25 years of age; 6) study designs were limited to observational analytical studies; 7) measured cannabis use. This review excluded other reviews, editorials, and conference abstracts that were not available as full text manuscripts. Independent review, risk of bias assessment, and data abstraction were performed by two authors.

Results

Fifteen articles from the United States (n=11) and Canada (n=4) were included in this review. The findings of this review showed that the prevalence of cannabis use during the pandemic among adolescents and young adults were mixed. Some mental health symptoms, including depression and anxiety, were identified as the most commonly reported reasons for increased cannabis use during the pandemic.

Conclusions

This review highlights the inconsistencies in the prevalence of cannabis use among adolescents and young adults during the pandemic. Therapeutic interventions for mental health and continued public health surveillance should be conducted to understand the long-term effects of cannabis use among adolescents and young adults.

Acute pediatric cannabis intoxication: A scoping review

Little is understood about the unintended consequences of cannabis liberalization on children. Subsequently, this scoping review aimed to map and identify evidence related to acute cannabis intoxication in children. We searched three medical literature databases from inception until October 2019. We identified 4644 information sources and included 158 which were mapped by topic area relating to 1) public health implications and considerations; 2) clinical management; and 3) experiences and information needs of HCPs and families. Public health implications were addressed by 129 (82%) and often reported an increased incidence of acute pediatric cannabis intoxications. Clinical information was reported in 116 (73%) and included information on signs and symptoms (n = 106, 92%), clinical management processes (n = 60, 52%), and treatment recommendations (n = 42, 36%). Few sources addressed the experiences or information needs of either HCPs (n = 5, <1%) treating children for acute cannabis intoxication or families (n = 1, <1%) seeking care. Increasing incidence of acute cannabis intoxications concurrent with liberalization of cannabis legislation is clear, however, evidence around clinical management is limited. Additionally, further research exploring HCPs and families experiences and information needs around cannabis intoxication is warranted.

Cannabis and children: risk mitigation strategies for edibles

In the era of (re)legalisation of medicinal and recreational cannabis, accidental and intentional exposure to edibles, cannabis-infused food products, has increased substantially. However, there is particular concern regarding younger age groups. Most concerning is the increase in hospitalisations. According to a study by Myran et al. (1), provinces in Canada, where the sale of edibles is permitted, saw an increase in paediatric poisonings due to unintentional consumption of edibles. Similar trends have been observed in "legalised states" in the US, such as Colorado (2). The impact of using cannabis at an early age, but particularly the impact of accidental exposure to high THC quantities, may have negative mental or physical health outcomes. Whilst regulatory restrictions vary significantly from one legalised region to another, it is difficult to identify a best practice. The aim of this study is to identify and discuss new and existing risk mitigation strategies to give guidance to policymakers. Furthermore, practical aspects, such as compliance (e.g. audits by authorities), are discussed. It is noted that edibles have been around much longer than recent political attempts to regulate them.

Reported exposures to derived cannabis products in California before and after the 2018 federal reclassification of hemp

BACKGROUND

As of June 2023, a majority of states had legalized the sale of cannabis, which past research has found to be associated with increased exposures. In 2018, a change in federal policy increased access to cannabidiol (CBD) and derived psychoactive cannabis products, but there has been limited study of reported exposures following this change.

METHODS

This observational retrospective study analyzed exposures involving synthetic cannabinoid receptor agonists (SCRAs) and derived cannabis products, including CBD, reported to the California Poison Control System (CPCS) from 2010 to 2022. We focused primarily on potential shifts in reported exposures before and after the implementation of the 2018 Farm Bill, which removed products derived from hemp from the Controlled Substances Act. We reviewed and hand-coded individual call records to assess reported exposures over time and their characteristics, and conducted interrupted time series analysis to assess whether exposure counts changed after policy interventions.

RESULTS

Reported CBD exposures significantly increased following the federal reclassification of hemp products. Exposure reports were most common among young children and for edibles. Exposure reports provided limited information about derived psychoactive cannabis products.

CONCLUSIONS

Our findings suggest a need for improved data collection regarding derived psychoactive cannabis products, as well as potential public health value in modifying packaging regulations and in providing additional guidance to parents to help prevent CBD exposures.

Social Media Marketing Practices of Illinois Recreational Cannabis Dispensaries in the First Year of Legal Sales: Product Promotions, Branding, and Price Promotions

Research from tobacco suggests that the recreational cannabis industry will use aggressive tactics, including product innovation and mass-marketing and advertising, to increase demand for their products. The purpose of this study is to examine product promotions, branding, and promotional pricing on recreational dispensary social media pages in the state of Illinois in the first year of legal sales. Data were collected from all recreational cannabis dispensary Facebook and Twitter accounts and a quantitative content analysis was used to analyze the data. Differences in marketing practices were assessed by neighborhood race/ethnicity and income and dispensary type. Results of the study revealed that flower and edibles were the two most heavily promoted products; promotions for vaporizers and concentrates were also promoted frequently. Posts with branded promotions and price promotions increased substantially over the year. Research suggests that this trend in marketing practices will lead to greater initiation and intensity of cannabis use.

The clouded debate: A systematic review of comparative longitudinal studies examining the impact of recreational cannabis legalization on key public health outcomes

Background

Ineffective cannabis regulatory frameworks such as prohibition have sparked interest in alternative solutions to reduce individual and societal harms. While it has been suggested that the recreational legalization process has yielded early successes, the relatively recent implementation of the novel policies has provided a modest time frame for a truly thorough establishment and assessment of key population-level indicators. The following systematic review focuses on identifying the downstream public health sequelae of cannabis legalization policies, including parameters such as cannabis consumption rates, hospitalization rates, vehicular accidents and fatalities, criminal activity, and suicidal behaviors, as well as other substance use trends.

Methods

An exhaustive search of the MEDLINE and Google Scholar databases were performed to identify high-quality (1) longitudinal studies, which (2) compared key public health outcomes between regions which had and had not implemented recreational cannabis legalization (RML) policies, (3) using distinct databases and/or time frames. Thirty-two original research articles were retained for review.

Results

Adult past-month cannabis consumption (26+ years) seems to have significantly increased following RML, whereas young adult (18-26 years) and adolescent (12-17 years) populations do not show a significant rise in past-month cannabis use. RML shows preliminary trends in increasing service use (such as hospitalizations, emergency department visits, or poisonings) or vehicular traffic fatalities. Preliminary evidence suggests that RML is related to potential increases in serious/violent crimes, and heterogeneous effects on suicidal behaviors. While the research does not illustrate that RML is linked to changing consumptions patterns of cigarette, stimulant, or opioid use, alcohol use may be on the rise, and opioid prescribing patterns are shown to be significantly correlated with RML.

Conclusion

The current data supports the notion that RML is correlated with altered cannabis consumption in adults, potentially increased criminal activity, and a decline in opioid quantities and prescriptions provided to patients. Future work should address additional knowledge gaps for vulnerable populations, such as individuals with mental health problems or persons consuming cannabis frequently/at higher THC doses. The effects of varying legalization models should also be evaluated for their potentially differing impacts on population-level outcomes.

Cannabis Use and Heart Transplantation: Disparities and Opportunities to Improve Outcomes

Heart transplantation (HT) remains the optimal therapy for many patients with advanced heart failure. Use of substances of potential abuse has historically been a contraindication to HT. Decriminalization of cannabis, increasing cannabis use, clinician biases, and lack of consensus for evaluating patients with heart failure who use cannabis all have the potential to exacerbate racial and ethnic and regional disparities in HT listing and organ allocation. Here' we review pertinent pre-HT and post-HT considerations related to cannabis use' and relative attitudes between opiates and cannabis are offered for context. We conclude with identifying unmet research needs pertaining to the use of cannabis in HT that can inform a standardized evaluation process.

Accidental Ingestion of Tetrahydrocannabinol-Laced Gummies Causing Bradycardia and First-Degree Atrioventricular Block in a Pediatric Patient: A Case Report

An increasing trend of cannabis use places children at risk for the detrimental effects of marijuana. Poison control centers in the United States have been experiencing an upsurge in calls involving marijuana ingestion among children in the past years, specifically in states where marijuana is legal. With marijuana ingestion, neurologic symptoms predominate but cardiovascular manifestations have also been observed. Bradycardia and bradyarrhythmia are both uncommon cardiac manifestations of cannabis ingestion in children. Here, we present the case of a previously healthy two-year-old male with sinus bradycardia and first-degree atrioventricular (AV) block following accidental ingestion of tetrahydrocannabinol-laced gummies. Although bradycardia and first-degree AV block are uncommon after cannabis ingestion in children, clinicians should be aware of these findings and must consider evaluating for marijuana toxicity whenever presented with these acute signs. Prevention is crucial and can be achieved through supervision, parental education, and support.

Edible marijuana products and potential risks for pediatric populations

PURPOSE OF REVIEW

In recent years, an increasing number of states have legalized marijuana, also known as cannabis, for recreational use. As marijuana becomes more accessible, adolescent use and accidental pediatric exposures are likely to become broad public health concerns. Edible marijuana products, which are consumable foods or beverages that contain cannabis extract, are particularly enticing to youth, as they come in appealing forms such as candies, cookies, and drinks. The purpose of this review is to provide pediatricians with an overview of the different types and potential dangers associated with edible marijuana products.

RECENT FINDINGS

Edible marijuana products are often indistinguishable in appearance from normal food items and lack the smell and visible smoke associated with inhaled marijuana. Because they are inconspicuous, palatable, and easily accessible, they are increasingly popular among adolescents. Additionally, the packaging of edible baked goods, candies, and drinks is often purposefully very similar to that of mainstream foods, increasing the risk of accidental ingestion by children. An edible marijuana product must be digested before Δ9-tetrahydrocannabinol can enter the bloodstream, so there is a delayed onset of effects when consuming edibles compared with inhaling marijuana. This also predisposes users to accidental overconsumption.

SUMMARY

Greater knowledge of edible marijuana product consumption by pediatric populations will allow pediatricians to more effectively help patients and advise caregivers in cases of overconsumption, dependence, or accidental ingestion. It is important for parents, guardians, and educators to be able to successfully identify edible marijuana products and recognize signs of cannabis use.

Presence of Content Appealing to Youth on Cannabis-Infused Edibles Packaging

BACKGROUND

There is a lack of consistent regulation of cannabis edibles packaging to restrict youth-appealing content in the United States.

OBJECTIVE

To describe content appealing to youth on U.S. cannabis-infused edibles packaging.

METHODS

We analyzed 256 photos of cannabis-infused edibles packaging collected from U.S. adults from 25 states, District of Columbia, and Puerto Rico between May 2020 to August 2021. We coded the presence of product knockoffs, human and non-human creatures, images indicating flavor, text indicating flavor, and the number of colors. We compared these codes across states' legalization status (medical and non-medical cannabis, medical cannabis only, or limited cannabis legalization).

RESULTS

Overall, 15% of packages resembled product knockoffs, 23% contained human/non-human creatures, 35% contained flavor images, 91% contained flavor text, and median number of colors was 5 (range from 1 to 10+). Packages purchased in states with medical and non-medical cannabis, medical cannabis only, or limited cannabis legalization differed significantly on product knockoffs (11%, 26%, 38%, p = 0.007), human/non-human creatures (19%, 33%, 63%, p = 0.002), flavor text (93%, 81%, 100%, p = 0.046), and number of colors (median of 5, 5, and 10, p = 0.022).

CONCLUSIONS

Existing laws have not adequately limited content appealing to youth on U.S. cannabis-infused edibles packaging. Robust and consistent regulations in the U.S. are needed to ensure that the packaging of such products does not contain content that appeal to youth and lead to initiation or inadvertent ingestion.

Changes in California cannabis exposures following recreational legalization and the COVID-19 pandemic

INTRODUCTION

Since 2012, eighteen states and the District of Columbia have legalized recreational cannabis. Past research suggests this policy change is associated with increased cannabis exposures however this has not yet been studied in California, despite its status as the world's largest legal cannabis market.

METHODS

This observational, retrospective study analyzed trends in cannabis exposures reported to the California Poison Control System (CPCS) from 2010 to 2020. We assessed shifts in exposures before and after the legalization of recreational cannabis in November 2016, the establishment of recreational retail sales in January 2018, and the institution of a statewide shelter-in-place order due to the COVID-19 pandemic in March 2020 using interrupted time-series analysis and reviewed all records to identify specific products associated with exposures.

RESULTS

Between 2010 and 2020 edible exposures increased from near zero to 79% of exposures in 2020. Cannabis exposures significantly increased following recreational legalization in 2016 (by an estimated 2.07 exposures per month [CI: 0.60, 3.55]; p < 0.01) and initiation of retail sales in 2018 (0.85 [CI: 0.12, 1.58]; p < 0.05). There was no significant change in cannabis exposures following the first shelter-in-place order of the COVID-19 pandemic (1.59 [CI: -1.61, 3.68]; p = 0.43). Cannabis exposures for those thirteen and under increased significantly both after recreational legalization (1.04 [CI: 0.38, 1.70]) and after the opening of the retail sales market (0.73 [CI: 0.34, 1.12]), but not following the shelter-in-place order (1.59 [CI: -1.61, 3.68]), nor was there a significant change for those older than thirteen.

CONCLUSIONS

Our findings suggest that cannabis legalization is linked to increased exposures, particularly for products such as gummies and candy edibles among children under the age of thirteen. Clinicians should be aware of these risks and communicate them to patients, and policymakers should consider stronger regulations on packaging to reduce these exposures.Key pointsQuestion: How have cannabis exposures changed following legalization of recreational use, the opening of the recreational retail sales market, and the institution of shelter-in-place orders during the COVID-19 pandemic?Findings: In this retrospective review of 10,757 cases reported to the California Poison Control System (CPCS) between 2010 and 2020, exposures increased significantly after the legalization of recreational cannabis use and the opening of the recreational retail sales market, particularly among children, who primarily consumed candies and gummies.Meaning: Stronger regulation of cannabis edibles that mimic other products is warranted to decrease exposures among children.

Heterogeneities in administration methods among cannabis users by use purpose and state legalization status: findings from a nationally representative survey in the United States, 2020

BACKGROUND AND AIMS

Different cannabis administration methods have differential impacts on health. This study aimed to describe administration methods among cannabis users in the United States categorized by (1) use purpose and (2) state legalization status.

DESIGN

Cross-sectional, probability-based online survey in 2020.

SETTING

All 50 states and Washington DC in the United States.

PARTICIPANTS

A total of 21 903 adults (18+) were recruited from a probability-based online panel to provide nationally representative estimates.

METHODS

Eleven administration methods were grouped into combustion, vaporization, ingestion and topicals. Weighted prevalence was reported among (1) medical-only, recreational-only and dual-purpose users based on self-reported purposes and (2) users in states that legalized both recreational and medical cannabis (RCL states), legalized medical cannabis only and did not legalize cannabis.

FINDINGS

Among past-year users, the proportions of medical-only, recreational-only and dual-purpose users were 25.55, 43.81 and 30.64%, respectively. The most common primary methods were combustion (42.08%) and topicals (28.65%) for medical purposes and combustion (72.07%) and ingestion (15.05%) for recreational purposes. Dual-purpose users were more likely to report combustion and vaporization but less likely to report ingestion and topicals as primary methods for medical use than medical-only users (P < 0.001) and more likely to report combustion and topicals but less likely to report ingestion as primary methods for recreational use than recreational-only users (P < 0.041). A higher proportion of dual-purpose users (82.82%) used more than one method than medical-only (40.52%) and recreational-only users (63.91%) (P < 0.001). For both medical and recreational purposes, RCL states had the lowest rate of combustion and the highest rates of ingestion and topicals reported as primary methods (P < 0.033). The rate of using more than one administration method did not differ across states (P > 0.05).

CONCLUSION

Cannabis users whose purposes are medical, recreational or both tend to differ in their selected administration methods.

Marijuana and Bariatric Surgery

PURPOSE OF REVIEW

Marijuana use presents a unique challenge to bariatric surgery programs. We review the recent evidence examining marijuana use on outcomes following bariatric surgery.

RECENT FINDINGS

Recent studies have not demonstrated an increased risk of short-term surgical complications or differences in up to 2-year weight loss following surgery among marijuana users. However, studies have demonstrated increased risks in two areas: pain management and problematic eating behaviors. Additionally, preoperative marijuana use has been linked to increased postoperative marijuana use which may undermine weight loss and increase risk for weight regain. There are still many unanswered questions regarding marijuana use and bariatric surgery, and the limited literature base has produced mixed results when considering marijuana as a contraindication for bariatric surgery. Programs must take into consideration the laws of their state, individual patterns of use, and route of administration when considering whether marijuana is a contraindication for surgery.

Children's Knowledge of Cannabis and Other Substances in States with Different Cannabis Use Regulations

Background: Public acceptance of cannabis continues to increase across the US, yet there has been little research on how cannabis legalization affects young children. The present study compared knowledge of cannabis and other substances among children living in states with different cannabis laws and examined whether the association between such substance knowledge and externalizing behavior varies by state cannabis regulations. Methods: Participants were from the Adolescent Brain Cognitive Development^SM Study (ABCD Study®) at the baseline assessment (N = 11,875, ages 9-11, collected from 2016 to 2018). Chi-square difference tests were used to compare nested models testing group differences in knowledge of substances and the association between externalizing disorder/behavior and substance knowledge as a function of state legality of cannabis use (recreational, medical, low THC/CBD, none). Results: Children living in states with more permissive cannabis laws had a greater knowledge of cannabis and reported more alcohol experimentation. In contrast, knowledge regarding alcohol, tobacco, and other illicit drugs was not greater in children from states with more permissive cannabis laws. Externalizing disorder/behavior was not significantly associated with cannabis knowledge in any group and not significantly different across groups. The association between externalizing disorder/behavior and illicit drug knowledge was significant only in states with the recreational and medical use laws but did not differ significantly across groups. Conclusion: Children living in environments with more permissive cannabis regulations have greater knowledge of cannabis, but not other substances, and report more experimentation with alcohol.

Characterizing the predictive validity of measures of susceptibility to future use of combustible, vaporized and edible cannabis products in adolescent never-users

BACKGROUND AND AIMS

The construct of susceptibility to substance use initiation (i.e. cognitive proclivity to future use) is critical for prevention efforts in adolescent populations. This study aimed to provide empirical evidence for the validity of the susceptibility construct for different cannabis products (i.e. combustible, edible or vaporized cannabis), and evaluate whether susceptibility measures are predictive of subsequent initiation.

DESIGN

Prospective cohort study including baseline data (Spring 2015) and four follow-up surveys administered every 6 months through Spring 2017.

SETTING

Ten schools in the Los Angeles, California metropolitan area.

PARTICIPANTS

Adolescents [n = 2100; mean age = 16.1; standard deviation (SD) = 0.41; 54% female] who reported never having used any cannabis product at baseline.

MEASUREMENTS

We assessed five indices of a susceptibility to use cannabis composite index at baseline, adapted from a validated tobacco use index (intention to use, willingness, curiosity and positive/negative cannabis use outcome expectancies, with four response categories, definitely not [1] to definitely yes [4]), by cannabis product (combustible, edible or vaporized). A composite index was created for each product by averaging responses across the five susceptibility items. Subsequent initiation of use of each cannabis product was assessed at each follow-up wave.

FINDINGS

Factorial validity for unidimensionality for each five-item index (by product) was confirmed. The composite index for susceptibility to cannabis use was greatest for combustible (mean = 1.44; SD = 0.58), moderate for edible (mean = 1.37; SD = 0.53) and lowest for vaporized cannabis (mean = 1.30; SD = 0.44). The associations of each composite susceptibility index with subsequent initiation of that product and each of the other cannabis products over follow-up (i.e. cross-product associations) were statistically significant, with hazard ratios ranging from 2.30 to 2.80 across 24 months of follow-up (all Ps < 0.05).

CONCLUSIONS

A five-item susceptibility to cannabis use composite index (by product) appears to be useful for characterizing and predicting youth at risk for cannabis use initiation across a spectrum of cannabis products.

Characterising heterogeneity in the use of different cannabis products: latent class analysis with 55 000 people who use cannabis and associations with severity of cannabis dependence

BACKGROUND

As new cannabis products and administration methods proliferate, patterns of use are becoming increasingly heterogeneous. However, few studies have explored different profiles of cannabis use and their association with problematic use.

METHODS

Latent class analysis (LCA) was used to identify subgroups of past-year cannabis users endorsing distinct patterns of use from a large international sample (n = 55 240). Past-12-months use of six different cannabis types (sinsemilla, herbal, hashish, concentrates, kief, edibles) were used as latent class indicators. Participants also reported the frequency and amount of cannabis used, whether they had ever received a mental health disorder diagnosis and their cannabis dependence severity via the Severity of Dependence Scale (SDS).

RESULTS

LCA identified seven distinct classes of cannabis use, characterised by high probabilities of using: sinsemilla & herbal (30.3% of the sample); sinsemilla, herbal & hashish (20.4%); herbal (18.4%); hashish & herbal (18.8%); all types (5.7%); edibles & herbal (4.6%) and concentrates & sinsemilla (1.7%). Relative to the herbal class, classes characterised by sinsemilla and/or hashish use had increased dependence severity. By contrast, the classes characterised by concentrates use did not show strong associations with cannabis dependence but reported greater rates of ever receiving a mental health disorder diagnosis.

CONCLUSIONS

The identification of these distinct classes underscores heterogeneity among cannabis use behaviours and provides novel insight into their different associations with addiction and mental health.

Complex cannabis use patterns: Associations with cannabis consequences and cannabis use disorder symptomatology

BACKGROUND

Historically, cannabis researchers have assumed a single mode and product of cannabis (e.g., smoking plant). However, patterns of use, products (e.g., concentrates, edibles), and modes (e.g. blunts, vaporizers) are diversifying. This study sought to: 1) classify cannabis users into groups based on their use of the full range of cannabis products, and 2) examine user group differences on demographics, cannabis consequences and cannabis use disorder (CUD) symptomatology.

METHODS

In a sample of college students (data collected in Fall 2017), who used cannabis in the past year (N = 1390), latent class analysis (LCA) was used to characterize cannabis users. We then added demographic characteristics, cannabis consequences, and CUD symptomatology scores separately to LCA models to examine class differences.

RESULTS

Five unique classes emerged: high-frequency all-product users, high-frequency plant/moderate-frequency edible and concentrate users, low-frequency plant users, moderate-frequency plant and edible users, and low-frequency edible users. Demographic characteristics, cannabis consequences, and CUD symptomatology differed across classes characterized by frequency as well as product.

CONCLUSIONS

Results reflect the increasing variety of cannabis products, modes, and use patterns among college students. In this sample, frequency of use remains a strong predictor of cannabis-related consequences, in addition to type of product. As variation in cannabis use patterns continue to evolve, it is essential for researchers to conduct comprehensive assessments.

Evaluation of Availability of Survey Data About Cannabis Use

IMPORTANCE

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

OBJECTIVE

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

DESIGN, SETTING, AND PARTICIPANTS

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

EXPOSURES

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

MAIN OUTCOMES AND MEASURES

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

RESULTS

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

CONCLUSIONS AND RELEVANCE

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

Modes of Marijuana Consumption Among Colorado High School Students Before and After the Initiation of Retail Marijuana Sales for Adults

OBJECTIVE

This study aimed to estimate the prevalence of different modes of marijuana consumption (e.g., smoking, ingesting) overall and by sociodemographic factors, marijuana-related perceptions, and other substance use among adolescents, as well as to characterize differences in the usual mode of consumption before and after the initiation of retail marijuana sales in 2014.

METHOD

Data are from the 2013 and 2015 administrations of the Healthy Kids Colorado Survey, a cross-sectional, school-based survey. We included 9th-12th grade students who reported past-30-day marijuana use in 2013 (n = 2,792; 44.8% female) or 2015 (n = 1,664; 48.9% female). We estimated the prevalence of any past-month use of each mode in 2015 and usual mode of consumption the past month in both years. We tested differences by year, sociodemographics, marijuana-related perceptions, and other substance use using Rao-Scott chi-square tests and multivariable logistic regression.

RESULTS

The prevalence of past-month marijuana use was 20.7% in both years. In 2015, 39.8% of students reported using multiple modes in the past month. Use of any mode other than smoking and use of multiple modes differed by sociodemographics, marijuana-related perceptions, and other substance use. Smoking remained the most common usual mode in 2015. The prevalence of usually ingesting significantly decreased from 4.7% to 2.1% between years, whereas "other mode(s)" significantly increased from 4.0% to 6.0%.

CONCLUSIONS

The use of multiple modes of marijuana consumption was prevalent among adolescents in Colorado. The usual mode of consumption changed in years before and after the implementation of retail marijuana sales, suggesting the need for continued surveillance.

Routes of cannabis administration among females in the year before and during pregnancy: Results from a pilot project

Use of cannabis during pregnancy is on the rise, yet little is known about how women administer cannabis during the perinatal period. This study examined self-reported modes of cannabis administration among women in the year before and during pregnancy, and their association with self-reported cannabis use frequency using data from 585 women screened in 2018-2019 for cannabis use during standard prenatal care in two medical centers in Northern California. The prevalence of cannabis use was 12% before pregnancy and 3% during pregnancy. Among the 71 women who reported cannabis use before pregnancy and the 19 women who reported cannabis use during pregnancy, smoking was the most common mode of administration (58% and 42%), followed by edibles (27% and 16%), vaping (23% and 16%), lotions (11% and 5%), and other (10% and 0%). In the year before pregnancy and during pregnancy, monthly or less use was most common (56% and 58%), followed by weekly use (24% and 26%) and daily use (20% and 16%). Among cannabis users, 43% used more than one mode before pregnancy compared to 15% during pregnancy. Daily cannabis use was most common among women who reported smoking only or smoking in combination with other modes. These novel results indicate that while smoking is the most common mode of cannabis administration during the perinatal period, there is variation in use and co-use of alternative modes. Future studies are needed to understand the relative health effects associated with individual and combined modes of cannabis administration during pregnancy.

Subjective effects of combustible, vaporized, and edible cannabis: Results from a survey of adolescent cannabis users

BACKGROUND

Data from controlled laboratory experiments in adults indicate that the subjective effects of cannabis vary by administration method (e.g., combustible, vaporized). Whether the subjective effects of cannabis experienced in the natural ecology and among adolescents differ by cannabis administration method is unknown. In this observational study, adolescents' retrospective reports of subjective effects after combustible, edible, and vaporized cannabis use were examined.

METHODS

Students from ten public schools in Los Angeles, CA, USA (M[SD] age = 16.1 [.43] years) who reported past 6-month use of combustible, edible, or vaporized cannabis (N = 584) were surveyed on subjective effects experienced after use (yes/no). They were provided with a 12 item self-report checklist of six positive (e.g., relaxed, energetic) and six negative (e.g., drowsy, lazy) subjective effects. For each method of administration, affirmative responses were summed in positive (range: 0-6) and negative (range: 0-6) effect composite scores.

RESULTS

Generalized estimating equations adjusted for demographics and recent cannabis use revealed a graded pattern of differences in positive subjective effects across products, with highest scores for combustible (M[SD] = 3.98[1.76]), followed by edible (M[SD] = 3.58 [2.04]) and vaporized (M[SD] = 3.11 [2.21]) cannabis (all pairwise cross-product contrasts p < .01). Mean negative effect score was highest for edible (M[SD] = 2.27 [1.95]), followed by combustible (M[SD] = 1.94 [1.66]), and vaporized (M[SD] = 1.34 [1.73]) cannabis, respectively (all pairwise contrasts p < .02).

CONCLUSION

Adolescents' reports of subjective effects varied across cannabis administration methods. Combustible cannabis' more desirable subjective effects profile might be indicative of higher abuse liability.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Aversiveness and Meaningfulness of Uncomfortable Experiences with Edible Cannabis

Cannabis remains the most frequently used illicit drug in the United States. As its legal status has changed, more people have turned to oral administration ("edibles"). 172 individuals who reported an uncomfortable experience with edible cannabis completed an online survey. Despite the aversive nature of the experience, 62.9% of the sample reported that the edible experience was at least somewhat meaningful and the majority of participants (95.2%) did not report any medical problems. The most common non-medical problem reported was going to bed early or lying down (75.8%). Most participants (69.2%) reported that dose was the key contributor to their negative experience. Participants who rated the experience as more aversive were less likely to use edibles again, r (167) = - .180, p < . 05. In addition, the duration of the aversive experience correlated positively with aversiveness rating, r (167) = . 244, p < . 05. With increased legalization of cannabis, edible use may rise. Dose seems to be associated with uncomfortable experiences with edible cannabis. Notwithstanding these uncomfortable experiences, the vast majority of the sample used cannabis edibles again, reported that the experience was at least somewhat meaningful, and did not report significant problems associated with the experience.

Cannabis-related emergencies in children and teens

PURPOSE OF REVIEW

To examine the spectrum of emergency department presentations associated with cannabis use or misuse that are currently seen in the pediatric population.

RECENT FINDINGS

There is a growing concern that pediatric emergency department visits related to cannabis are on the rise, especially given rapidly changing legislation on cannabis and its broad availability in certain areas. These concerns are substantiated in the current literature, as the evidence mounts for an array of emergency department presentations of intentional or accidental cannabis use. The range of presentations documented in the recent literature spans gastrointestinal, psychiatric and cardiorespiratory effects, in addition to traumatic injuries and accidental ingestions by younger children. Complications of chronic cannabis use, such as 'cannabis hyperemesis syndrome', depression, psychosis or cognitive impairment, are now recognized outcomes and even more are likely to emerge.

SUMMARY

An array of cannabis-related symptoms is possible from acute use or exposure. Common presentations include acute intoxication, hyperemesis, depression and acute physical injuries from impaired psychomotor function. Uncommon presentations include cardiorespiratory effects, and a range of symptoms in young children that include hyperkinesis and coma. Clinical vigilance is needed to suspect and clinically diagnose cannabis exposure in the emergency department.

Medical Cannabis Use in Glioma Patients Treated at a Comprehensive Cancer Center in Florida

Background: Glioma is a devastating primary tumor of the central nervous system with difficult-to-manage symptoms. Cannabis products have been postulated to potentially benefit glioma patients. Recent state legalization allowed investigators an opportunity to study glioma patients' adoption of medical marijuana (MM). Objective: Our goals were to: (1) determine the prevalence of marijuana use, both through physician recommendation and self-medication, and (2) evaluate its perceived risks and benefits in glioma patients. Design: Self-report data were collected and descriptive analyses were conducted. Setting/Subjects: Participants were adult, English-speaking patients undergoing treatment for primary non-recurrent malignant glioma in neuro-oncology clinics at an NCI-designated Comprehensive Cancer Center. Measurements: The survey on MM was adapted from previous research and included questions on knowledge and attitudes toward MM; use, frequency, type, and sourcing of MM; and reasons for use of MM and perceived symptom relief among users. Results: A total of 73 patients were surveyed. The majority of participants were aware that MM was legal in the state, and most reported learning of this through the media. Over 70% of participants reported having considered using MM, and a third reported using marijuana products after their diagnosis. Most received recommendations from friends/family rather than a medical provider, and only half of the users had obtained a physician's recommendation. Users generally reported benefits. Conclusions: With the increasing national conversation that accompanies legalization, glioma patients are pursuing marijuana for the treatment for their symptoms. More research and education is needed to bring health care providers into the conversation.

Acute Illness Associated With Cannabis Use, by Route of Exposure: An Observational Study

BACKGROUND

Little is known about the relative harms of edible and inhalable cannabis products.

OBJECTIVE

To describe and compare adult emergency department (ED) visits related to edible and inhaled cannabis exposure.

DESIGN

Chart review of ED visits between 1 January 2012 and 31 December 2016.

SETTING

A large urban academic hospital in Colorado.

PARTICIPANTS

Adults with ED visits with a cannabis-related International Classification of Diseases, Ninth or 10th Revision, Clinical Modification (ICD-9-CM or ICD-10-CM), code.

MEASUREMENTS

Patient demographic characteristics, route of exposure, dose, symptoms, length of stay, disposition, discharge diagnoses, and attribution of visit to cannabis.

RESULTS

There were 9973 visits with an ICD-9-CM or ICD-10-CM code for cannabis use. Of these, 2567 (25.7%) visits were at least partially attributable to cannabis, and 238 of those (9.3%) were related to edible cannabis. Visits attributable to inhaled cannabis were more likely to be for cannabinoid hyperemesis syndrome (18.0% vs. 8.4%), and visits attributable to edible cannabis were more likely to be due to acute psychiatric symptoms (18.0% vs. 10.9%), intoxication (48% vs. 28%), and cardiovascular symptoms (8.0% vs. 3.1%). Edible products accounted for 10.7% of cannabis-attributable visits between 2014 and 2016 but represented only 0.32% of total cannabis sales in Colorado (in kilograms of tetrahydrocannabinol) during that period.

LIMITATION

Retrospective study design, single academic center, self-reported exposure data, and limited availability of dose data.

CONCLUSION

Visits attributable to inhaled cannabis are more frequent than those attributable to edible cannabis, although the latter is associated with more acute psychiatric visits and more ED visits than expected.

PRIMARY FUNDING SOURCE

Colorado Department of Public Health and Environment.

Cannabis Oil Use by Adolescents and Young Adults With Inflammatory Bowel Disease

OBJECTIVES

The aim of the study was to describe use of oral or sublingual cannabis oil (CO) by adolescent and young adult patients with inflammatory bowel disease (IBD).

METHODS

A descriptive study of IBD patients 13 to 23 years of age seen between January 2015 through December 2017 at Children's Hospital Colorado. Information obtained included chart abstraction, electronic and interview self-report, and serum cannabinoid levels. We compared CO users and cannabis non-users for clinical characteristics and perceptions of risk. Users of CO provided information on routes, patterns, motivations, and perceived benefits and problems with use.

RESULTS

The 15 users and 67 non-users were similar for clinical characteristics and pain and appetite scores. 9 of 15 (60%) CO users had used in the past 30 days, an average of 22 ± 9 times; and 4 used daily. A variety of strengths and CBD:THC ratios were reported. Most common perceived effect of use was on sleep quality, nausea, and increase in appetite. Of the 15 users, 6 used only CO and no additional forms of cannabis. Of these 6 CO only users, 5 reported a medical reason for use, most commonly to relieve pain.

CONCLUSIONS

Adolescent and young adults with IBD used oral CO and many used other cannabis products as well. Users perceived some medical benefit. Care teams should strive for open communication about use until further information on safety and efficacy becomes available.

Acute cannabis toxicity

Objective: We describe the clinical effects of, and products associated with, acute exposures to cannabis during the early legalization period of recreational cannabis in Oregon and Alaska. Methods: This was an observational study of Oregon/Alaska Poison Center data between 4 December 2015 and 15 April 2017. A standardized data collection instrument was created for this study that captured information about cannabis product description, route of exposure, intentional vs unintentional exposure, product dose, product manufacture source, product ownership source, initial vital signs, clinical signs and symptoms, and subject disposition. Subjects were included if the Poison Center received a call about an acute exposure to cannabis from the subject, subject's family member or friend, or healthcare worker participating in the subject's care. Subjects were excluded if there was no evident exposure, the exposure was chronic, there were co-ingestants, or the subject was non-human (e.g. pet). Results: Two hundred fifty three individuals were acutely exposed to cannabis (median age 20 years; range 8 months - 96 years; 54.2% males): 71 (28.1%) children (<12 years), 42 (16.6%) adolescents (12-17 years), and 140 (55.3%) adults (≥18 years). Children were most likely to unintentionally (98.6%) ingest (97.2%) homemade (35.2%) edibles (64.8%) belonging to a family member (73.2%) and experience sedation (52.1%). Adults were most likely to intentionally (88.6%) ingest (66.4%) retail (40.0%) edibles (48.6%) and experience neuroexcitation (47.1%). Adolescents' exposures had similarities to both adult and children; they were most likely to intentionally (81.0%) ingest (50.0%) homemade (23.8%) edibles (45.2%) belonging to a friend (47.3%) and to experience either neuroexcitation (42.9%) or sedation (40.5%). Among all ages, tachycardia and neuroexcitation were more likely following inhalation exposures compared to ingestions. Eight subjects were admitted to an intensive care unit, including three patients who were intubated; one subject died. Edibles were the most common products to cause symptoms in all age groups, while concentrated products were more likely to lead to intubation, especially when ingested. Children in particular had a higher likelihood of intensive care unit admission and intubation following exposure to concentrated products. Conclusions: Neurotoxicity is common after acute cannabis exposures. Children experienced unintentional exposures, particularly within the home and occasionally with major adverse outcomes. Concentrated products such as resins and liquid concentrates were associated with greater toxicity than other cannabis products. These findings may help guide other states during the early retail cannabis legalization period.

Prevalence and Sociodemographic Correlates of Adolescent Use and Polyuse of Combustible, Vaporized, and Edible Cannabis Products

IMPORTANCE

Cannabis legalization and commercialization have introduced novel alternative cannabis products, including edible and vaporized cannabis that might appeal to youth and be associated with polyuse (ie, use of ≥2 different products).

OBJECTIVE

To investigate the prevalence, patterns, and sociodemographic correlates of cannabis product use across combustible, edible, and vaporized administration methods, including polyuse of cannabis via multiple administration methods.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional survey study included 10th-grade students from 10 Los Angeles, California, area high schools from January 2 through October 6, 2015. Students were recruited from respondents in the Happiness and Health Study, an ongoing prospective cohort study in the 10 high schools. Students not in school during administration of the pencil-and-paper survey completed abbreviated surveys by telephone, internet, or mail. Data were analyzed from July 17, 2017, through July 12, 2018.

EXPOSURES

Self-reported sex, race/ethnicity, and socioeconomic status (SES). Students with high SES had parents who attained college or a higher educational level and were ineligible for free or subsidized lunch; those with low SES had parents with lower educational attainment or were eligible for free or subsidized lunch.

MAIN OUTCOMES AND MEASURES

Self-report of ever use (yes or no) and past 30-day use (yes or no) status and frequency of use (days in past 30 days) of combustible, edible, and vaporized cannabis.

RESULTS

The sample included 3177 tenth-grade students (93.5% of study enrollees); among these students, 1715 (54.0%) were girls and the mean (SD) age was 16.1 (0.4) years. Among those with available demographic data, respondents were diverse in race/ethnicity (537 [17.2%] Asian; 149 [4.8%] black; 1510 [48.3%] Hispanic; 507 [16.2%] white; 207 [6.6%] multiethnic/multiracial; and 216 [6.9%] other) and included 1654 (60.1%) with a low SES. Prevalence of ever use was highest for combustible products (993 [31.3%]), followed by edible (676 [21.3%]) and vaporized (333 [10.5%]) products. A similar pattern was found for past 30-day use (426 [13.4%] for combustible, 249 [7.8%] for edible, and 156 [4.9%] for vaporized cannabis). Among participants who reported using cannabis in the past 30 days, mean frequency of use of combustible cannabis was higher by 2.65 days (95% CI, 1.40-3.91 days, P = .001) than the mean frequency of use for edible cannabis and 1.75 days higher (95% CI, 0.59-2.90 days, P = .003) than frequency of use for vaporized cannabis. Most cannabis users (665 [61.7%]) used multiple administration methods, and 260 (8.2%) used all 3 methods. Boys had higher prevalence of ever use for vaporized (170 [11.6%] vs 163 [9.5%]) but not combustible (459 [31.4%] vs 534 [31.1%]) or edible (303 [20.7%] vs 373 [21.7%]) cannabis. Respondents with low SES had higher prevalence of ever use for combustible (614 [37.1%] vs 242 [22.0%]) and edible (408 [24.7%] vs 166 [15.1%]) but not vaporized (186 [11.2%] vs 93 [8.5%]) cannabis.

CONCLUSIONS AND RELEVANCE

Among 10th-grade students in Los Angeles, use of cannabis via alternative administration methods was of appreciable prevalence, predominately reported in conjunction with other cannabis products and unequally distributed across sociodemographic strata. Prevention programs and regulatory restrictions addressing the spectrum of cannabis products might benefit pediatric public health.

Understanding emerging forms of cannabis use through an online cannabis community: An analysis of relative post volume and subjective highness ratings

BACKGROUND

Legalization of medical and recreational cannabis has coincided with an increase in novel forms of cannabis use and a burgeoning cannabis product industry. This research seeks to understand the occurrence of discussions about these emerging and traditional forms of use in an online social media discussion forum.

METHODS

We analyzed posts to a cannabis-specific forum on the Reddit social media platform posted from January 2010-December 2016. For each of various keywords describing smoking, vaping, edibles, dabbing, and butane hash oil (BHO) concentrate use, we analyzed (1) relative prevalence of posts mentioning these cannabis forms of use; (2) user-reported subjective ratings of "highness" on a scale of 1-10; (3) the ten most common words mentioned in posts; and (4) the frequency of adverse health effect terms.

RESULTS

Form of use was mentioned in approximately 17.7% of 2.26 million posts; smoking was the most commonly mentioned form of cannabis use. From 2010-2016, relative post volume increased significantly for posts mentioning dabbing (3.63/1000 additional posts per year, p < .001), butane hash oil terms (3.16/1000, p < .001), and edible terms (2.84/1000, p = .002). Mean subjective highness was significantly greater for posts mentioning dabbing (mean = 7.8, p < .001), butane hash oil terms (mean = 7.5, p < .001), and edible terms (mean = 7.2, p < .001) but not significantly different for vaping (mean = 6.7, p = .19), when compared to smoking (mean = 6.8).

CONCLUSIONS

Despite limitations in representativeness, findings indicate a significant increase in online discussion of emerging cannabis forms of use over time and greater subjective effects of dabbing, butane hash oil, and edible use.

Use of Marijuana Edibles by Adolescents in California

We explored how adolescent marijuana edible users differ in regards to marijuana use and related beliefs from marijuana users who do not use edibles. We analyzed California Healthy Kids Survey data collected in one Northern California school district with a racially and ethnically diverse student population. Survey respondents were youth in grades 9-12. Overall, 33% of respondents reported having used marijuana in their lifetime, and 50% of lifetime marijuana users reported using marijuana in the past 30 days. Seventy-two percent of lifetime marijuana users and 82% of past month marijuana users reported having used edibles in their lifetime. Comparing marijuana users who have never used edibles to those users who have, we found that edible users reported using marijuana more frequently in their lifetime. Edible users were also more likely to have used marijuana in the past 30 days, more frequently in the past 30 days, more likely on school property and more frequently on school property. Edible users and non-users differed in their perceptions of risk; edible users were less likely to agree that edible use is very risky. Edible users also reported a younger age of first marijuana use and more attempts to stop using marijuana than non-edible users. Multi-level regression analyses indicate that prevalence of edible use among marijuana users was related to perceived risk of edible use. Perceived risk of edible use among marijuana users was higher among marijuana users who do not use edibles, females, and those youth who perceive school rules to be clear. The findings indicate that prevalence of edible use is high among marijuana users, especially frequent users.

Regulating Cannabis Manufacturing: Applying Public Health Best Practices from Tobacco Control

State legalization and regulation of cannabis, despite continued federal illegality, is a massive shift in regulatory approach. Manufactured cannabis, including concentrates, extracts, edibles, tinctures, topicals and other products, has received less attention than more commonly used dried flower, but represents emerging regulatory challenges due to additives, potency, consumption methods, and abuse and misuse potential. In November 2017, the California Department of Public Health (CDPH) released initial cannabis manufacturing regulations as part of a new state regulatory structure. As the largest U.S. medical cannabis market (and largest legal adult use market in the world beginning in 2018), California's regulatory approach will potentially influence national and global policy. Comparing CDPH's initial regulations to tobacco control best practices reveals that, while the regulations recognize the need to protect public health, prioritizing public health over business interests requires stronger approaches to labeling, packaging, and product formulations. Based on tobacco best practices, we recommend that cannabis regulations incorporate large and proportionately sized informational labels, a prominent universal cannabis symbol, rotating and pictorial health warnings, mandatory plain packaging, a comprehensive ban on characterizing flavors and addictive additives, and strict limits on the potency of inhalable products and those easily confused with non-cannabis products.

Medical marijuana in pediatric oncology: A review of the evidence and implications for practice

Medical marijuana (MM) has become increasingly legal at the state level and accessible to children with serious illness. Pediatric patients with cancer may be particularly receptive to MM, given purported benefits in managing cancer-related symptoms. In this review, we examine the evidence for MM as a supportive care agent in pediatric oncology. We describe the current legal status of MM, mechanism of action, common formulations, and potential benefits versus risks for pediatric oncology patients. We offer suggestions for how providers might approach MM requests. Throughout, we comment on avenues for future investigation on this growing trend in supportive care.

Cannabis use among middle and high school students in Ontario: a school-based cross-sectional study

BACKGROUND

Cannabis use can have serious detrimental effects in children and adolescents. It is therefore important to continually assess the use of cannabis among young people in order to inform prevention efforts. We assessed the prevalence of cannabis use among middle and high school students in Ontario and examined its association with demographic and behavioural factors.

METHODS

Data were obtained from the 2015 Ontario Student Drug Use and Health Survey, a province-wide school-based survey of students in grades 7 through 12. Analyses included a representative sample of 9920 middle and high school students. Bivariate cross-tabulations and logistic regression analyses were used to investigate the factors associated with cannabis use.

RESULTS

Overall, 21.5% and 13.9% of students reported using cannabis in the previous year and previous month, respectively. The conditional probability that an adolescent who reported cannabis use in the previous year would report daily use was 12.5%. There was a significant dose-response gradient with age, with older students being more likely to use cannabis than younger students. In multivariable analyses, being in grades 10 through 12 (odds ratios [ORs] ranged from 3.71 to 3.85), being black (OR 2.67 [95% confidence interval (CI) 1.76-4.05]), using tobacco cigarettes (OR 10.10 [95% CI 8.68-13.92]) and being an occasional (OR 5.35 [95% CI 4.01-7.13]) or regular (OR 14.6 [95% CI 10.8-19.89]) alcohol user were associated with greater odds of cannabis use. Being an immigrant was associated with lower odds of cannabis use (OR 0.55 [95% CI 0.39-0.78]).

INTERPRETATION

The findings suggest that cannabis use is prevalent among middle and high school students in Ontario and is strongly associated with tobacco cigarette smoking and alcohol consumption. Future research should document trends in cannabis use over time, including its risks, especially when the legalization of recreational cannabis comes into effect.