Marijuana sources in a medical marijuana environment: dynamics in access and use among a cohort of young adults in Los Angeles, California

Investigating Cannabis-Use Among Students Attending High Schools Within the Cherokee Nation Reservation 2017 and 2019

Oklahoma's medical cannabis is some of the least restrictive in the US. Previous research suggests that American Indian/Alaska Native (AIAN) have higher rates of cannabis use than other racial or ethnic groups. The goals of this paper are, first, to look at cannabis use among high school students living on the Cherokee Nation Reservation before (2017) and after (2019) medical cannabis because legal in Oklahoma (2018) utilizing the Cherokee Nation Youth Risk Behavior Survey (CNYRBS). Second, to describe the socio-demographic characteristics of youth using cannabis in the Cherokee Nation Reservation. Data were retrieved from the 2017 and 2019 CNYRBS. The data for this study included 1,216 high school students who completed the 2017 and 1,476 who completed the 2019 CNYRBS. After removal of incomplete records, there were 2,602 students whose data was analyzed in this study. Data were weighted to be representative of public-school students attending grades 9-12 within Cherokee Nation Reservation. Despite the legalization of medical cannabis in Oklahoma in 2018, there was no change in cannabis use among youth between 2017 and 2019. There were variations in cannabis use based on demographic factors and other substance uses. AIAN individuals had higher odds of current cannabis use compared to non-Hispanic White students, but there were no differences based on ethnicity. Additionally, the use of cigarettes, e-cigarettes, alcohol, and illegal drugs were associated with increased odds of cannabis use among both current and former users compared to those who had never used it. There was no spike in use among youth at least immediately after the legalization of cannabis in the Cherokee Nation Reservation. There were socio-demographic as well as substance use disparities in the use of cannabis.

Pre-Post Cannabis Legalization for Adult Use: A Trend Study of Two Cohorts of Young Adult Cannabis Users in Los Angeles

Cannabis was legalized for adult use in California in 2016 for individuals 21 and older. Among 18-20-years-olds, who can possess cannabis legally as medical cannabis patients (MCP) but not as non-patient cannabis users (NPU), the impact of adult use legalization (AUL) on cannabis and other substance use is unknown. Two cohorts of 18-20-year-old cannabis users (MCP and NPU) were surveyed, one in 2014-15 (n = 172 "pre-AUL") and another in 2019-20 (n = 139 "post-AUL"), using similar data collection methods in Los Angeles, California. Logistic and negative binomial regressions estimated cohort and MCP differences for cannabis and other drug use outcomes based on past 90-day use. In both pre- and post-AUL cohorts, MCP were more likely to self-report medical cannabis use (p < .001) while the post-AUL cohort reported greater use of edibles (p < .01), but fewer mean days of alcohol (p < .05) and cigarette (p < .01) use in multivariate models. Notably, frequency of cannabis use (days or hits per day) did not significantly differ between the pre- and post-AUL cohorts, except for greater use of edibles, despite potentially greater access to cannabis.

Public perceptions of medical cannabis diversion: A legal and moral dilemma

The study examined public perception in Israel of the severity of medical cannabis diversion, its morality, and normativeness. The sample included 380 participants who completed a quantitative questionnaire to respond to four scenarios about diverting medical cannabis to a person with/without a license and with/without a small payment (a 2×2 design). The findings show that although the participants received advance information about the severity of medical cannabis diversion as a drug trafficking offense, they perceived the severity of the offense as moderate, and as an act that is at least moderately moral and normative. The findings are explained based on moral theories. We discuss the implications of the findings in relation to the gap between public attitudes and legal policy.

Reasonable access: important characteristics and perceived quality of legal and illegal sources of cannabis for medical purposes in Canada

BACKGROUND

Throughout the past two decades of legal medical cannabis in Canada, individuals have experienced challenges related to accessing legal sources of cannabis for medical purposes. The objective of our study was to examine the sources of cannabis accessed by individuals authorized to use medical cannabis and to identify possible reasons for their use of illegal sources.

METHODS

Individuals who participated in the Cannabis Access Regulations Study (CANARY), a national cross-sectional survey launched in 2014, and indicated they were currently authorized to use cannabis for medical purposes in Canada were included in this study. We assessed differences between participants accessing cannabis from only legal sources versus from illegal sources in relation to sociodemographic characteristics, health-related factors, and characteristics of medical cannabis they considered important. A secondary analysis assessed differences in satisfaction with various dimensions of cannabis products and services provided by legal versus illegal sources.

RESULTS

Half of the 237 study participants accessed cannabis from illegal sources. Individuals accessing cannabis from illegal sources were significantly more likely to value pesticide-free products, access to a variety of strains, ability to select strain and dosage, ability to observe and smell cannabis, availability in a dispensary, and availability in small quantities than did individuals accessing cannabis from only legal sources (all p < 0.05). Additionally, participants gave significantly higher satisfaction scores to illegal sources than to legal sources on service-related dimensions of cannabis access (all p < 0.05).

CONCLUSION

Our findings contribute to an understanding of reasonable access to medical cannabis from a patient perspective and how to assess whether it has been achieved. Characteristics of cannabis products and services valued by patients and appropriate to their needs should be incorporated into legal medical cannabis programs to promote the use of legal medical sources. While pertaining specifically to medical use of cannabis in Canada, the findings of this study may also be instructive for understanding the use of illegal cannabis sources for non-medical purposes in Canada and provide insight for other jurisdictions implementing cannabis regulations for both medical and non-medical purposes.

Qualitative Research on Cannabis Use Among Youth: A Methodological Review

Recreational cannabis legalization has encouraged research regarding cannabis use among youth, especially the use of qualitative approaches. In fact, alcohol and drug use journals have recently encouraged qualitative submissions and provided criteria to ensure “high-quality” research. This study provides an objective account of the qualitative approaches used by researchers in this field and discusses implications for future research. A methodological review was conducted for studies published between January 2010 and November 2019. Targeted keyword searches in four research databases returned 1956 unique records. Pairs of reviewers independently screened records against eligibility criteria and charted data for study philosophical positioning, methodology, study aims, sampling, sample, data collection, and data analysis. 23 studies met the inclusion criteria. Several gaps in study quality criteria are observed: less than half of the studies specified the overarching methodology and just two stated philosophical positioning, with some methods unjustified. Implications for future research are discussed.

Characteristics that influence purchase choice for cannabis products: a systematic review

Introduction

When non-medical cannabis use became legal, government regulators implemented policies to encourage safer consumption through access to a regulated market. While this market is growing, sales still occur through unregulated channels. This systematic review identifies factors influencing cannabis purchasing to help policymakers understand why consumers still purchase illicit market cannabis (registered with PROSPERO CRD42020176079).

Methods

A comprehensive search strategy included databases in health, business, and social science fields (inception to June 2020). Studies were eligible for inclusion if they were conducted with persons who purchase cannabis and examine at least one attribute that would influence purchase choice and were published in the English language. Studies could be of any methodological design. Two independent reviewers completed two levels of screening, and all extraction was verified by a second reviewer. A qualitative synthesis of the findings was completed. The quality of the included studies was assessed using the Mixed Methods Appraisal Tool.

Results

Of the 4839 citations screened, 96 were eligible for full-text review and 35 were included in the final synthesis. Aspects of price were the most common factors (27 studies). Twenty studies measured price elasticity; most studies found that demand was price inelastic. Many other attributes were identified (e.g., product quality, route of administration, product recommendations, packaging), but none were explored in depth. Eleven studies addressed aspects of product quality including demand elasticity based on quality, potency, and aroma. Studies also explored consumer-perceived “quality” but provided no definition; differences in quality appeared to impact consumer choice. Smoking cannabis appeared to be the preferred route of administration but was only examined in three studies. There was insufficient data to understand in the impact of other attributes on choice. There appeared to be preference heterogeneity for different attributes based on the consumer’s experience, reason for use, and gender.

Conclusion

While price influences choices, demand is relatively inelastic. This suggests that consumers may be seeking lowest-cost, unregulated cannabis to avoid reducing consumption. Beyond price, there is a significant gap in our understanding of consumer choices. Perceived quality does appear to impact choice; however, more research is needed due to the lack of a recognized definition for cannabis quality.

Supplementary Information

The online version contains supplementary material available at 10.1186/s42238-022-00117-0.

COVID-19’s Impact on Substance Use and Well-Being of Younger Adult Cannabis Users in California: A Mixed Methods Inquiry

Few qualitative studies have examined the impact of COVID-19 on cannabis and alcohol use, and overall well-being among cannabis users. Cannabis users (aged 26-32) were surveyed quantitatively (n=158) and interviewed qualitatively (n=29) in April 2020–May 2021 in Los Angeles. 63.3% of the quantitative sample reported increasing use of either cannabis (29.1%) or alcohol (15.2%) or both (19.0%) following the COVID-19 outbreak. Qualitative data revealed that increases in cannabis and alcohol use were largely attributed to changes in employment and staying at home resulting in fewer impediments and boredom. Themes of loneliness and utilization of various coping strategies were more pronounced among those who increased cannabis and/or alcohol use. For some, increases in cannabis/alcohol use were temporary until participants adjusted to “a new normal” or embraced more adaptive coping strategies. Results suggest monitoring cannabis/alcohol use trends and identifying coping strategies to reduce the pandemic’s impact on substance use and mental health.

Analysis of State Cannabis Laws and Dispensary Staff Recommendations to Adults Purchasing Medical Cannabis

IMPORTANCE

Over the last decade, cannabis has become more accessible through the proliferation of dispensaries in states that have legalized its use. Most patients using cannabis for medical purposes report getting advice from dispensaries, yet there has been little exploration of frontline dispensary staff practices.

OBJECTIVE

To describe the practices of frontline dispensary workers who interact with customers purchasing cannabis for medical purposes and assess whether dispensary practices are associated with medicalization of state cannabis laws (degree to which they resemble regulation of prescription or over-the-counter drugs) and statewide adult use.

DESIGN, SETTING, AND PARTICIPANTS

This nationwide cross-sectional survey study was conducted from February 13, 2020, to October 2, 2020, using an online survey tool. Potential respondents were eligible if they reported working in a dispensary that sells tetrahydrocannabinol-containing products and interacting with customers about cannabis purchases.

MAIN OUTCOMES AND MEASURES

Participant responses to questions about formulating customer recommendations and talking to customers about risks.

RESULTS

The 434 survey responses from 351 unique dispensaries were most often completed by individuals who identified as budtenders (40%), managers (32%), and pharmacists (13%). Most respondents reported basing customer recommendations on the customer's medical condition (74%), the experiences of other customers (70%), the customer's prior experience with cannabis (67%), and the respondent's personal experience (63%); fewer respondents relied on clinician input (40%), cost (45%), or inventory (12%). Most respondents routinely advised customers about safe storage and common adverse effects, but few counseled customers about cannabis use disorder, withdrawal, motor vehicle collision risk, or psychotic reactions. A higher state medicalization score was significantly associated with using employer training (odds ratio, 1.41; 95% CI, 1.18-1.67) and physician or clinician input (odds ratio, 1.23; 95% CI, 1.05-1.43) as a basis for recommendation. Medicalization score was not associated with counseling about cannabis risks.

CONCLUSIONS AND RELEVANCE

This survey study provides insight into how frontline dispensary staff base cannabis recommendations and counsel about risks. The findings may have utility for clinicians to counsel patients who purchase cannabis, customers who want to be prepared for a dispensary visit, and policy makers whose decisions affect cannabis laws.

Changes in Medical Cannabis Patient Status before and after Cannabis Legalization in California: Associations with Cannabis and Other Drug Use

It is unknown how patterns of cannabis and other drug use changed among young adult cannabis users as they became, exited or stayed medical cannabis patients (MCPs) after California legalized cannabis for adult use in 2016. A cohort of 18-26 year-old cannabis users was recruited in Los Angeles in 2014-15 (64.8% male; 44.1% Hispanic/Latinx). Based on wave 1 (pre-legalization) and wave 4 (post-legalization) MCP status, four transition groups emerged: MCP, Into MCP, Out of MCP and NPU (non-patient user). Relationships between self-reported medical cannabis use, transition group membership, and cannabis/other drug use outcomes were examined. Changes in cannabis practices were consistent with changes in MCP status. Cannabis days, concentrate use, self-reported medical cannabis use and driving under influence of cannabis were highest among MCP, increased for Into MCP, and decreased for Out of MCP in wave 4. A majority of drug use outcomes decreased significantly by wave 4. Self-reported medical cannabis use was associated with more frequent cannabis use but less problematic cannabis and other drug use. Future studies should continue to monitor the impact of policies that legalize cannabis for medical or recreational use, and medical motivations for cannabis use on young adults' cannabis and other drug use.

Seeking safety: a focus group study of young adults' cannabis-related attitudes, and behavior in a state with legalized recreational cannabis

BACKGROUND

Only July 1, 2017, Nevada became the fifth US state to allow the legal sale of recreational cannabis products for adults ages of 21 and over. This study investigates young adults' cannabis-related attitudes, perceptions, and behaviors in a state where recreational and medical cannabis use was recently legalized.

METHODS

We conducted 8 focus groups stratified by cannabis use (regular users, occasional users, and nonusers) with 32 college students ages 18 to 24. Data were analyzed using the inductive qualitative thematic analysis method.

RESULTS

Four themes emerged during analyses: "sort of legal," "mitigating harm through legalization," "Increasing acceptance," and "seeking safety when purchasing cannabis." Despite their limited knowledge of cannabis regulation, the majority of the participants supported recreational cannabis legalization from a harm reduction perspective. Most participants did not believe that cannabis legalization had affected their use behavior. However, participants, especially cannabis users, perceived that recreational cannabis legalization created a context where cannabis use was legally, socially, and behaviorally "safer" than in an illegal context, even for those below the legal age of sale.

CONCLUSIONS

Most studies focus on the role of perceived health risk on cannabis use. If there are population-level long-term effects of recreational cannabis legalization on use behavior, findings suggest that they will be mediated by the perceived legal, social, and behavioral risk of using cannabis.

Facing the option for the legalisation of cannabis use and supply in New Zealand: An overview of relevant evidence, concepts and considerations

ISSUES

Non-medical cannabis policies are changing, including towards legalisation-with-regulation frameworks. New Zealand will hold a public referendum on cannabis legalisation in 2020. We reviewed data on cannabis use and health/social harms; policy reform options; experiences with and outcomes of reforms elsewhere; and other relevant considerations towards informing policy choices in the upcoming referendum.

APPROACH

Relevant epidemiological, health, social, criminal justice and policy studies and data were identified and comprehensively reviewed.

KEY FINDINGS

Cannabis use is common (including in New Zealand) and associated with risks for health and social harms, mainly concentrated in young users; key harms are attributable to criminalisation. 'Decriminalisation' reforms have produced ambivalent results. Existing cannabis legalisation frameworks vary considerably in main parameters. Legalisation offers some distinct advantages, for example regulated use, products and user education, yet outcomes depend on essential regulation parameters, including commercialisation, and policy ecologies. While major changes in use are not observed, legalisation experiences are inconclusive to date, including mixed health and social outcomes, with select harms increasing and resilient illegal markets. It is unclear whether legalisation reduces cannabis exposure or social harms (e.g. from enforcement) for youth.

IMPLICATIONS/CONCLUSIONS

No conclusive overall evidence on the outcomes of legalisation elsewhere exists, nor is evidence easily transferable to other settings. Legalisation offers direct social justice benefits for adults, yet overall public health impacts are uncertain. Legalisation may not categorically improve health or social outcomes for youth. Legalisation remains a well-intended, while experimental policy option towards more measured and sensible cannabis control and overall greater policy coherence, requiring close monitoring and possible adjustments depending on setting-specific outcomes.

Comparison of Male and Female Patients in Louisiana Medical Marijuana Dispensaries

Relatively little is known in terms of patient demographics, indications, previous cannabis use, or the forms and dosages of medical marijuana (MM) dispensed for patients at MM dispensaries. Even less is known in terms of how male and female patients may differ in each of these aspects. The goal of the current study was to examine each of these variables using a retrospective analysis of deidentified patient data from MM dispensaries in Louisiana. Deidentified data were analyzed from web-based pharmacist-patient consultations at MM dispensaries throughout Louisiana. Data were collected during the first 6 months following the initiation of the MM dispensing program in Louisiana. A total of 1195 MM patients (598 male/597 female) were included in the analyses. The average age of the sample was 51.9 years (±14.8) and it was composed primarily of white patients (86.7%). Males and females were nearly identical in terms of average age, race, previous cannabis use, indication profile, and MM recommendations. Differences between males and females were observed in terms of opioid use, history of psychosis, presence of more than one indication, and the duration of previous cannabis use. Our data indicate that, in MM dispensaries of the Deep South state, there are numerous similarities-and some potentially important differences-between male and female MM patients. The importance of these differences, and the importance of continued data collection/analysis, for improving MM dispensing are discussed.

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

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