Minimizing the adverse public health effects of cannabis legalization

Emerging adult perceptions of cannabis consumption: Examining changes in perceptions from pre-legalization to post-legalization

BACKGROUND

Emerging adults (EAs) have the highest rates of cannabis consumption in Canada and are vulnerable to the potential impacts of frequent cannabis consumption. This study assessed EAs' perceived risk of cannabis consumption across multiple domains of potential harm based on the age (14-year-old, 21-year-old, or 28-year-old) and sex (male or female) of the vignette character, time-point (pre- or post-legalization), and participant's gender.

METHODS

Secondary analyses were conducted on data from a pre-legalization study and post-legalization replication. Participants included EAs between 18 and 25 years of age and living in Newfoundland and Labrador. Participants from the pre- and post-legalization studies were matched based on demographic variables and the assigned vignette character. Participants responded to seven items of perceived risk based on their assigned vignette character's (varied by age or sex) almost daily cannabis consumption.

RESULTS

Participants (N = 689) viewed cannabis consumption to have greater risks for a 14-year-old compared to a 21- or 28-year-old in all domains except for social life. Prior to legalization, participants who identified as a woman felt that cannabis had more detrimental impacts on social life than participants who identified as a man. Findings also suggested that pre-legalization cannabis consumption by a female was perceived as more detrimental to their social life than pre-legalization consumption by a male and post-legalization consumption by a female.

CONCLUSION

EAs do not fully appreciate the risks of cannabis consumption, suggesting that it is imperative for public health strategies to promote increased awareness of the risks of frequent cannabis consumption, and improve cannabis health literacy in this population.

The Information-Seeking Behavior and Unmet Knowledge Needs of Older Medicinal Cannabis Consumers in Canada: A Qualitative Descriptive Study

INTRODUCTION

Older Canadians (age 60+) are increasingly using cannabis to treat their health problems, but little is known regarding how they learn about medicinal cannabis. This study explored the perspectives of older cannabis consumers, prospective consumers, healthcare professionals, and cannabis retailers on older adults' information-seeking behavior and unmet knowledge needs.

METHODS

A qualitative descriptive design was used. Semi-structured telephone interviews were conducted with a purposeful sample of 36 older cannabis consumers and prospective consumers, as well as 4 healthcare professionals and 5 cannabis retailers from across Canada, for a total sample of 45 participants. Data were thematically analyzed.

RESULTS

Three main themes characterizing older cannabis consumers' information-seeking were identified: (1) knowledge sources, (2) types of information sought, and (3) unmet knowledge needs. Participants accessed a variety of knowledge sources to inform themselves about medicinal cannabis. Cannabis retailers were identified as providing medical information to many older adults, despite regulations to the contrary. Cannabis-specialized healthcare professionals were also viewed as key knowledge sources, while primary care providers were perceived as both knowledge sources and gatekeepers limiting access to information. The types of information participants sought included the effects and potential benefits of medicinal cannabis, the side effects and risks involved, and guidance regarding suitable cannabis products. Participants' most salient unmet knowledge needs focused on dosing and use of cannabis to treat specific health conditions.

DISCUSSION

Findings suggest that barriers to learning about medical cannabis among older consumers identified in prior research remain pervasive and cut across jurisdictions. To address these barriers, there is a need for better knowledge products tailored to older cannabis consumers and their information needs, and further education for primary healthcare providers on medicinal cannabis and its therapeutic applications with older patients.

Impacts of medical and non-medical cannabis on the health of older adults: Findings from a scoping review of the literature

BACKGROUND

Cannabis legalization has enabled increased consumption in older adults. Age-related mental, physical, and physiological changes may lead to differences in effects of cannabis in older adults compared to younger individuals.

OBJECTIVE

To perform a scoping review to map the evidence regarding the health effects of cannabis use for medical and non-medical purposes in older adults.

METHODS

Electronic databases (MEDLINE, Embase, PsycINFO, Cochrane Library) were searched for systematic reviews (SRs), randomized controlled trials (RCTs) and non-randomized/observational studies (NRSs) assessing the health effects and associations of cannabis use (medical or non-medical) in adults ≥ 50 years of age. Included studies met age-related inclusion criteria or involved a priori identified health conditions common among older adults. Records were screened using a liberal accelerated approach and data charting was performed independently by two reviewers. Descriptive summaries, structured tables, effect direction plots and bubble plots were used to synthesize study findings.

FINDINGS

From 31,393 citations, 133 publications describing 134 unique studies (26 SRs, 36 RCTs, 72 NRSs) were included. Medical cannabis had inconsistent therapeutic effects in specific patient conditions (e.g., end-stage cancer, dementia), with a number of studies suggesting possible benefits while others found no benefit. For medical cannabis, harmful associations outnumbered beneficial, and RCTs reported more negative effects than NRSs. Cannabis use was associated with greater frequencies of depression, anxiety, cognitive impairment, substance use and problematic substance use, accidents/injuries, and acute healthcare use. Studies often were small, did not consistently assess harms, and did not adjust for confounding.

DISCUSSION

The effects of medical cannabis are inconsistent within specific patient conditions. For older adults, generally, the available evidence suggests cannabis use may be associated with greater frequencies of mental health issues, substance use, and acute healthcare use, and the benefit-to-risk ratio is unclear. Studies with a balanced assessment of benefits and harms may guide appropriate public health messaging to balance the marketing pressures of cannabis to older adults.

Cannabis-only use in the USA: prevalence, demographics, use patterns, and health indicators

Background

The prevalence of adults who consume cannabis while abstaining from other substances is not known in the USA. This study used nationally representative data to estimate the prevalence and explore the demographic characteristics, cannabis use behaviors, and self-reported health of US adults with past 30-day cannabis-only use, as compared with adults who used cannabis as well as other substances.

Methods

Data came from adults 18 years and older who responded to the 2017 or 2018 National Survey on Drug Use and Health and reported past 30-day cannabis use (n = 12,143). Cannabis-only use was defined as past 30-day cannabis use with no past 30-day use of other substances (alcohol, tobacco, other illicit substances, non-prescribed controlled medications). Weighted frequencies and 95% confidence intervals (CI) were computed for all sociodemographic and cannabis-related variables, overall, and across the two categories of cannabis consumers, stratified by age.

Results

The prevalence of past 30-day cannabis-only use among US adults was 0.9% (95% CI: 0.8, 1.0) and varied by age (2.0% of 18–25 years old; 0.7% of 26–49 year olds, and 0.6% of those ≥ 50 years). Among adults with any past 30-day cannabis use, 8.4% (95% CI: 7.6, 9.2; n = 980) reported cannabis-only use. Age was significantly associated with past 30-day cannabis-only use, with adults 18–25 years and 26–49 years having higher odds of cannabis-only use compared with older adults. Past year cannabis dependence was lowest among cannabis-only consumers aged ≥ 50 years (0.2%; 95% CI: 0.1, 0.5) and highest among young adult cannabis and other substance consumers (16.7%; 95% CI: 15.3, 18.2). Past year prevalence of any mental illness was generally similar across cannabis use groups and by age.

Conclusions

The prevalence of adult cannabis-only use in the US is low — most cannabis consumers report using other substances in the past 30 days as well. While cannabis-only use among older adults is rare, it does not appear to be accompanied by a high prevalence of dependence. These findings should guide future research and policymaking.

A Systematic Review and Narrative Synthesis of the Evolution of Adolescent and Young Adult Cannabis Consumption Before and After Legalization

PURPOSE

To systematically review evidence assessing the evolution of cannabis consumption before and after the implementation of non-medical cannabis legislation.

METHODS

MEDLINE, PubMED, PsycINFO, Scopus, and Web of Science were systematically searched for studies that examined change in cannabis consumption before and after nonmedical cannabis legislation. Data were tabulated by study design, levels of consumption, and individual subgroups. Data were analyzed using a narrative synthesis approach, considering study quality.

RESULTS

32 studies were included (11 higher quality and 21 lower quality). 40% of higher quality evidence supported an increase in postlegalization consumption (55% did not report a change and 5% reported a decrease). The increase was most evident for young adults (42% of higher quality evidence) and in the consumption in the past month (37% of higher quality evidence). There was limited supporting evidence for new users having grown in response to legalization. Based on subgroup analysis, the increase in postlegalization consumption was higher among women and those who engage in binge-drinking.

CONCLUSIONS

Higher quality evidence suggests an increase in adolescent past-month consumption of cannabis following legalization in several geographical jurisdictions. Consumption evolution prelegalization and postlegalization differed by age group and for young women and for binge drinkers. Consumption evolution differences suggest a variety of strategies might be required in efforts to lower public health impacts of cannabis consumption following legalization.

Interactions of protective behavioral strategies and cannabis use motives: An online survey among past-month users

Given the constant high prevalence of cannabis use and cannabis dependence, it is important to determine protective behaviors on the individual level, which buffer the effects of risk factors. Protective Behavioral Strategies for Marijuana (PBSM) have been identified to play an important role for harm reduction in adolescent and young adult users. In the present study, we analyzed if PBSM moderate the effects of use motives (captured by the Marijuana Motives Measure, MMM) on the severity of dependence beyond the effects of age, gender, education and cannabis use frequency. We used confirmatory factor analysis (CFA) to validate the German versions of PBSM and MMM. Data was gathered in an online survey distributed to randomly chosen households in the city of Bern in the German speaking part of Switzerland. The final sample comprised 362 past-month users. Results showed negative correlations between PBSM and cannabis use frequency and severity of dependence. The only motives being correlated with severity of dependence were coping and routine, beyond frequency of use. PBSM significantly moderated the effect only of routine motives on the severity of dependence. However, only a few cases who used PBSM extensively were affected. PBSM appear to be an important factor to reduce harm among past-month users but not among those with dependent use patterns, e.g. coping and routine users. Clinical implications are discussed. The routine factor adds significantly to the MMM and should be implemented and improved in future studies. PBSM as well as the MMM can be used in future studies in German speaking populations.

Exploring New Use of Cannabis among Older Adults

Objectives: In Canada, cannabis prohibition ended in October 2018. Older adults are the fastest growing group of cannabis users and are out-pacing other groups as new users. Clinical evidence indicates that cannabis may be helpful for select medicinal purposes in this population. Yet there is limited research about older adults experiences of starting to use cannabis in later life. The purpose of this study was to begin to address this gap. Methods: This study employed qualitative description. A convenience sample of Canadian community-dwelling older adults who were new users of cannabis were recruited. Data were collected using semi-structured interviews. Data analysis was inductive and thematic. Results: Twelve older adults between the ages of 71 and 85 participated. All of the participants used cannabis for medicinal reasons, however, only one had a prescription. The main reasons for using were: pain management, alternative to prescription or over-the-counter medication, and sleep aide. Most participants obtained cannabis from non-licensed stores. Eleven discussed cannabis use with their family physicians, however, none received prescriptions from them. The main sources of information were friends, cannabis store staff, and the media. Conclusions: Older adults who begin using cannabis are likely using for what they perceive to be medicinal purposes for a range of issues. However, they receive minimal guidance from their family physicians and instead obtain information from non-clinician sources. Clinical implications: Cannabis screening should be included in geriatric assessments and medicine reconciliation. Continuing education for clinicians needs to address knowledge gaps about cannabis use among older adults.

The Lower-Risk Cannabis Use Guidelines' (LRCUG) recommendations: How are Canadian cannabis users complying?

Canada, alongside other jurisdictions, implemented non-medical cannabis legalization in 2018, partly towards improving public health. Evidence-based 'Lower-Risk Cannabis Use Guidelines' (LRCUG), including recommendations for cannabis users on how to decrease risk-behaviors for harms, have been developed and widely disseminated in Canada since 2017. However, knowledge on users' compliance with the LRCUG is limited. We identified four major Canadian (three national, one provincial) population surveys presenting key data on cannabis-related behaviors: the National Cannabis Survey, Canadian Cannabis Survey, Canadian Tobacco, Alcohol & Drugs Survey, and CAMH Monitor. We scanned each survey for indicator data mapping onto either of the LRCUG's recommendations for the years 2017 to 2019. Relevant indicator data, albeit with varying operationalizations, were found for six of the ten LRCUG's recommendation clusters in at least some of the surveys, and were extracted and summarized. For results, substantial -- but declining -- majorities of users consumed cannabis by smoking, yet with shifts towards other use modes. Between one- to two-in-five users engaged in the risk-behaviors of using high-potency cannabis products, frequent cannabis use and cannabis-impaired driving, respectively. A small proportion of pregnant or breastfeeding women continued cannabis use during the study period. The data identified found suggested a heterogeneous picture regarding cannabis users' compliance with the LRCUG's recommendations. Non-compliance is highest for recommendations regarding modes-of-use, and applies to minorities of users for other risks factors. These sub-groups are at elevated risk for acute (e.g., accidents) or long-term (e.g., dependence) cannabis-related harms contributing to the public health burden. Appropriate targeted interventions in these areas require improvement.