Outcomes, Registries and Medical Marijuana: Towards Establishing Dispensary Monitoring and Reporting Standards

Are recreational cannabis laws associated with declining medical cannabis program enrollment in the U.S.? An analysis of cardholder enrollment and demographic characteristics from 2013 to 2020

BACKGROUND

There is speculation that enrollment in U.S. state medical cannabis programs differs depending on whether adult recreational cannabis use is legal. If true, this could have implications for public health and policy.

METHODS

Using medical cannabis registry data from U.S. states with a mandatory registry between 2013 and 2020 (N = 23 states), this study examined time-trends in medical cannabis cardholder enrollment and tested whether enrollment trends differed depending on adult recreational cannabis legalization.

RESULTS

Multilevel models showed that time-trends for registered active medical cardholders differed during years when adult recreational cannabis use was legal versus not legal (time*recreational cannabis law interaction: b = -0.004, p < 0.01, 95% CI = -0.005, -0.003). The population prevalence of registered active medical cardholders increased over time in years when recreational cannabis was not legal (i.e., medical-only years; b = 0.004, p < 0.001, 95% CI = 0.003, 0.004, corresponding to an increase of 380 cardholders per 100,000 people per year), and decreased in years when recreational cannabis was legal (i.e., recreational years; b = -0.001, p < 0.001, 95% CI = -0.002, -0.001, corresponding to a decrease of 100 cardholders per 100,000 people per year). Time-trends were similar for each sex (male, female) and age group (18-30/35, 30/35+), with each cardholder group showing increases in medical-only years and decreases in recreational years. In medical-only years, there were no differences in enrollment time-trends across sex, but older cardholder (30/35+) enrollment increased at a faster rate than younger cardholder enrollment (18-30/35) (F = 16.199, p < 0.001). In recreational years, male cardholder enrollment decreased at a faster rate than female cardholder enrollment (F = 7.347, p < 0.01), but there was no difference in trends across age. Three states, all with medical-only years, provided data on ethnicity/race. Results showed significant increases from 2016 to 2020 in enrollment of White, African-American, and Hispanic individuals.

CONCLUSIONS

Findings suggest that recreational cannabis legalization is associated with decreasing enrollment in medical cannabis programs, particularly for males.

A Practice Based Behavioral Health Management Registry (BHMR): Implementation, Structure and Content

Previous commentaries in the Formulary Evaluation section of INNOVATIONS in Pharmacy have pointed to the difficulties of establishing the credibility of trial-based and modeled claims for therapy interventions. Claims for interventions in behavioral health are no exception. A recent report by The Kennedy Forum emphasizes the need for a system of measurement-based care using validated scales to assess the need for and response to therapy. To accomplish this, The Kennedy Forum proposed a core set of outcomes measures for behavioral health interventions. This core set provides the context for a proposed Behavioral Health Management Registry (BHMR). The purpose of this commentary is to describe the structure and content of the BHMR. The BHMR provides access to nine symptom rating scales for depression, mania, anxiety, PTSD, panic attacks, alcohol use, drug abuse and somatization, together with supplementary questions to capture socio-demographic characteristics of patients, pain experience and opioid use, medical marijuana, DSM-V criteria for PTSD diagnosis and sleep experience. As such, with patient and physician inputs over the course of treatment, the BHMR provides an evidence base for physician practices and health care decision makers to evaluate behavioral health interventions by tracking the cumulative response to therapy. In addition, the BHMR captures the perception of the patients as to whether or not their therapy has led to any substantive improvement in activity limitations, symptoms and quality of life. A particular focus of the BHMR is on monitoring and evaluating the impact of interventions on the overall experience of pain as well as tracking pain intensity and functional status by body location. This is important given the prevalence of pain and its association with conditions such as depression and anxiety. The BHMR can also support monthly reports to the practice to summarize patient throughput, the response to care by target pain patients and profiles of opioid use and abuse. The BHMR can be customized to meet the needs of individual practices.

Establishing Practice Risk Management and Outcomes Claims for Medical Marijuana Dispensaries: Questions Legislators Should Ask

In a previous commentary in INNOVATIONS in Pharmacy, the case was made that a major oversight in approving the establishment of medical marijuana programs through commercially and not-for-profit operated dispensaries is the failure to put in place standards for the monitoring and reporting of outcomes. It was pointed out that the evidence base is limited for the range of dosing options, administrative routes and conditions treated. The concern is that the ease that patients have in obtaining medical marijuana certification in many states means that a medical marijuana program is, in effect, little different from a recreational program. Dispensaries understandably focus on sales and returns to investors with scant attention given to tracking and reporting outcomes across the range of conditions and symptoms presented. While this no doubt appeals to investors in reducing administration costs, it makes it virtually impossible to deliver the appropriate and coordinated level of care that patients should expect if a medical marijuana dispensary is to meet it responsibilities in its duty of care. This places dispensaries at malpractice risk. Given this, this commentary focuses on the questions that legislators should ask in licensing medical marijuana dispensaries to ensure they meet a defensible duty of care to their patients.