Marijuana self-report compared with testing in trauma patients before and after legalization

Health, safety, and socioeconomic impacts of cannabis liberalization laws: An evidence and gap map

Background

Globally, cannabis laws and regulations are rapidly changing. Countries are increasingly permitting access to cannabis under various decriminalization, medicalization, and legalization laws. With strong economic, public health, and social justice incentives driving these domestic cannabis policy reforms, liberalization trends are bound to continue. However, despite a large and growing body of interdisciplinary research addressing the policy-relevant health, safety, and socioeconomic consequences of cannabis liberalization, there is a lack of robust primary and systematic research that comprehensively investigates the consequences of these reforms.

Objectives

This evidence and gap map (EGM) summarizes the empirical evidence on cannabis liberalization policies. Primary objectives were to develop a conceptual framework linking cannabis liberalization policies to relevant outcomes, descriptively summarize the empirical evidence, and identify areas of evidence concentration and gaps.

Search Methods

We comprehensively searched for eligible English-language empirical studies published across 23 academic databases and 11 gray literature sources through August 2020. Additions to the pool of potentially eligible studies from supplemental sources were made through November 2020.

Selection Criteria

The conceptual framework for this EGM draws upon a legal epidemiological perspective highlighting the causal effects of law and policy on population-level outcomes. Eligible interventions include policies that create or expand access to a legal or decriminalized supply of cannabis: comprehensive medical cannabis laws (MCLs), limited medical cannabidiol laws (CBDLs), recreational cannabis laws (RCLs), industrial hemp laws (IHLs), and decriminalization of cultivations laws (DCLs). Eligible outcomes include intermediate responses (i.e., attitudes/behaviors and markets/environments) and longer-term consequences (health, safety, and socioeconomic outcomes) of these laws.

Data Collection and Analysis

Both dual screening and dual data extraction were performed with third person deconfliction. Primary studies were appraised using the Maryland Scientific Methods Scale and systematic reviews were assessed using AMSTAR 2.

Main Results

The EGM includes 447 studies, comprising 438 primary studies and nine systematic reviews. Most research derives from the United States, with little research from other countries. By far, most cannabis liberalization research focuses on the effects of MCLs and RCLs. Studies targeting other laws-including CBDLs, IHLs, and DCLs-are relatively rare. Of the 113 distinct outcomes we documented, cannabis use was the single most frequently investigated. More than half these outcomes were addressed by three or fewer studies, highlighting substantial evidence gaps in the literature. The systematic evidence base is relatively small, comprising just seven completed reviews on cannabis use (3), opioid-related harms (3), and alcohol-related outcomes (1). Moreover, we have limited confidence in the reviews, as five were appraised as minimal quality and two as low quality.

Authors’ Conclusions

More primary and systematic research is needed to better understand the effects of cannabis liberalization laws on longer-term-and arguably more salient-health, safety, and socioeconomic outcomes. Since most research concerns MCLs and RCLs, there is a critical need for research on the societal impacts of industrial hemp production, medical CBD products, and decriminalized cannabis cultivation. Future research should also prioritize understanding the heterogeneous effects of these laws given differences in specific provisions and implementation across jurisdictions.

Cannabis positivity rates in 17 emergency departments across the United States with varying degrees of marijuana legalization

BACKGROUND

Many states in the United States have progressed towards legalization of marijuana including decriminalization, medicinal and/or recreational use. We studied the impact of legalization on cannabis-related emergency department visits in states with varying degrees of legalization.

METHODS

Seventeen healthcare institutions in fifteen states (California, Colorado, Connecticut, Florida, Iowa, Kentucky, Maryland, Massachusetts, Missouri, New Hampshire, Oregon, South Carolina, Tennessee, Texas, Washington) participated. Cannabinoid immunoassay results and cannabis-related International Classification of Diseases (ninth and tenth versions) codes were obtained for emergency department visits over a 3- to 8-year period during various stages of legalization: no state laws, decriminalized, medical approval before dispensaries, medical dispensaries available, recreational approval before dispensaries and recreational dispensaries available. Trends and monthly rates of cannabinoid immunoassay and cannabis-related International Classification of Diseases code positivity were determined during these legalization periods.

RESULTS

For most states, there was a significant increase in both cannabinoid immunoassay and International Classification of Diseases code positivity as legalization progressed; however, positivity rates differed. The availability of dispensaries may impact positivity in states with medical and/or recreational approval. In most states with no laws, there was a significant but smaller increase in cannabinoid immunoassay positivity rates.

CONCLUSIONS

States may experience an increase in cannabis-related emergency department visits with progression toward marijuana legalization. The differences between states, including those in which no impact was seen, are likely multifactorial and include cultural norms, attitudes of local law enforcement, differing patient populations, legalization in surrounding states, availability of dispensaries, various ordering protocols in the emergency department, and the prevalence of non-regulated cannabis products.

Validity between self-report and biochemical testing of cannabis and drugs among patients with traumatic injury: brief report

Background

The relationship between drug use and traumatic injury is well documented, yet only a small proportion of patients are biochemically tested for cannabis and other substances. The study objective was to determine whether patient self-report can be used as a proxy for biochemical drug testing following traumatic injury.

Methods

This study was a secondary analysis that included 320 patients admitted to four level I trauma centers in Colorado and Texas, primarily involved in motor vehicle crash (89%). If performed, biochemical testing was collected via urine toxicology screen (“tox screen”) for cannabis, amphetamines, barbiturates, cocaine, opiates, PCP, and benzodiazepines. All patients were screened for self-reported current drug use, which was evaluated for any drug and specifically for cannabis use. Analyses used to compare results of self-reported drug use and tox screen included sensitivity, specificity, positive, and negative predictive values, and percent agreement.

Results

Among 320 patients, 23% (n = 75) self-reported drug use; cannabis was the most frequently reported drug (n = 63). A tox screen was performed in 59% of patients (n = 190); the proportion of patients who had a tox screen was similar for those self-reporting drug use (60.0%) to those who denied using drugs (59.2%), p = 0.90. Among patients who had a tox screen performed, 18% (n = 35) tested positive for any drug, 12% (n = 22) tested positive for THC, and 7% (n = 13) tested positive for opiates. The percent agreement was 80% for any drug and 81% for cannabis. The specificity was 84–85%, indicating a high likelihood that a patient will not have a positive tox screen if they do not report using drugs. Negative predictive values were 90–95%, indicating a negative self-report correctly identified nearly all patients testing negative on tox screen. Sensitivity was only 60% and positive predictive values were 30–47% for cannabis and drugs, respectively.

Conclusion

These findings may negate the need for biochemical drug testing in this population, particularly as a “rule out” based on self-reporting. Future studies are needed to confirm these findings and should address risk of selection bias.

Impact of recreational cannabis legalization on patient self-reporting of cannabis use at a pharmacist-led primary care clinic

BACKGROUND

The Cannabis Act, introduced in Canada in 2018, legalized the use of recreational cannabis. The impact of the announcement and implementation of this act on patient self-reporting of cannabis use has not been explored.

OBJECTIVE

The study objective was to determine if patient self-reported cannabis use increased after the announcement and implementation of legislative changes to legalize recreational cannabis.

METHODS

A repeated cross-sectional design was used for a retrospective chart review of patients seen at a pharmacist-led primary care clinic. A convenience sample of patient records was divided into 3 panels, corresponding with the preannouncement (November 1, 2013-October 4, 2015), postannouncement (October 5, 2015-October 16, 2018), and postimplementation (October 17, 2018-October 17, 2019) stages of the legalization of recreational cannabis. Search terms used included cannabis, marijuana, marihuana, recreational drugs, natur∗, medicinal, pot, joint, oil, butter, brownies, edibles, cannabin∗, THC, tetrahydro∗, sativa, and indica (∗ = string wild card). The frequency of reporting use and the number of queries related to cannabis were assessed. The analysis of variance test and Pearson correlation (chi-square) were used to compare the 3 panels.

RESULTS

A total of 298 patient charts were included in the analysis. One hundred, 99, and 99 patient charts corresponded with panels 1, 2, and 3, respectively. At each time point, 6%, 8%, and 14% of the patients reported cannabis use (P = 0.03). A statistically significant increase in topical oil use and a decrease in prescription tablet or capsule use between panels 1 and 3 (P = 0.036) were identified.

CONCLUSION

This study found an increase in self-reporting of cannabis use across the 3 consecutive panels. The change in the product formulations used may reflect the various products available. Frontline pharmacists are encouraged to initiate conversations regarding cannabis use as part of routine practice.

New Designer Drugs

In recent years, there has been an emergence of numerous novel drugs. Such toxicity may occur in both adolescents and adults. This article discusses the opioid epidemic and several emerging opioids, including buprenorphine, loperamide, fentanyl, fentanyl derivatives, and others. Kratom, a plant occasionally used for opiate detoxification, along with the sedatives etizolam and phenibut, will be discussed. Lastly, this article discusses the phenethylamines and marijuana.