Chronic Pain, Cannabis Legalization and Cannabis Use Disorder in Veterans Health Administration Patients, 2005 to 2019.
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SUBMITTER: Hasin DS
PROVIDER: S-EPMC10370240 | biostudies-literature | 2023 Jul
REPOSITORIES: biostudies-literature
Publications
Chronic Pain, Cannabis Legalization and Cannabis Use Disorder in Veterans Health Administration Patients, 2005 to 2019.
Hasin Deborah S DS Wall Melanie M MM Alschuler Dan D Mannes Zachary L ZL Malte Carol C Olfson Mark M Keyes Katherine M KM Gradus Jaimie L JL Cerdá Magdalena M Maynard Charles C CC Keyhani Salomeh S Martins Silvia S SS Fink David S DS Livne Ofir O McDowell Yoanna Y Sherman Scott S Saxon Andrew J AJ
medRxiv : the preprint server for health sciences 20230712
<h4>Background</h4>The risk for cannabis use disorder (CUD) is elevated among U.S. adults with chronic pain, and CUD rates are disproportionately increasing in this group. Little is known about the role of medical cannabis laws (MCL) and recreational cannabis laws (RCL) in these increases. Among U.S. Veterans Health Administration (VHA) patients, we examined whether MCL and RCL effects on CUD prevalence differed between patients with and without chronic pain.<h4>Methods</h4>Patients with ≥1 prim ...[more]
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Project description:ImportanceCannabis use disorder (CUD) is increasing among US adults. Few national studies have addressed the role of medical cannabis laws (MCLs) and recreational cannabis laws (RCLs) in these increases, particularly in patient populations with high rates of CUD risk factors.ObjectiveTo quantify the role of MCL and RCL enactment in the increases in diagnosed CUD prevalence among Veterans Health Administration (VHA) patients from 2005 to 2019.Design, setting, and participantsStaggered-adoption difference-in-difference analyses were used to estimate the role of MCL and RCL in the increases in prevalence of CUD diagnoses, fitting a linear binomial regression model with fixed effects for state, categorical year, time-varying cannabis law status, state-level sociodemographic covariates, and patient age group, sex, and race and ethnicity. Patients aged 18 to 75 years with 1 or more VHA primary care, emergency department, or mental health visit and no hospice/palliative care within a given calendar year were included. Time-varying yearly state control covariates were state/year rates from American Community Survey data: percentage male, Black, Hispanic, White, 18 years or older, unemployed, income below poverty threshold, and yearly median household income. Analysis took place between February to December 2022.Main outcomes and measuresAs preplanned, International Classification of Diseases, Clinical Modification, ninth and tenth revisions, CUD diagnoses from electronic health records were analyzed.ResultsThe number of individuals analyzed ranged from 3 234 382 in 2005 to 4 579 994 in 2019. Patients were largely male (94.1% in 2005 and 89.0% in 2019) and White (75.0% in 2005 and 66.6% in 2019), with a mean (SD) age of 57.0 [14.4] years. From 2005 to 2019, adjusted CUD prevalences increased from 1.38% to 2.25% in states with no cannabis laws (no CLs), 1.38% to 2.54% in MCL-only enacting states, and 1.39% to 2.56% in RCL-enacting states. Difference-in-difference results indicated that MCL-only enactment was associated with a 0.05% (0.05-0.06) absolute increase in CUD prevalence, ie, that 4.7% of the total increase in CUD prevalence in MCL-only enacting states could be attributed to MCLs, while RCL enactment was associated with a 1.12% (95% CI, 0.10-0.13) absolute increase in CUD prevalence, ie, that 9.8% of the total increase in CUD prevalence in RCL-enacting states could be attributed to RCLs. The role of RCL in the increases in CUD prevalence was greatest in patients aged 65 to 75 years, with an absolute increase of 0.15% (95% CI, 0.13-0.17) in CUD prevalence associated with RCLs, ie, 18.6% of the total increase in CUD prevalence in that age group.Conclusions and relevanceIn this study of VHA patients, MCL and RCL enactment played a significant role in the overall increases in CUD prevalence, particularly in older patients. However, consistent with general population studies, effect sizes were relatively small, suggesting that cumulatively, laws affected cannabis attitudes diffusely across the country or that other factors played a larger role in the overall increases in adult CUD. Results underscore the need to screen for cannabis use and CUD and to treat CUD when it is present.
| S-EPMC9979011 | biostudies-literature
Project description:AbstractIn the United States, cannabis is increasingly used to manage chronic pain. Veterans Health Administration (VHA) patients are disproportionately affected by pain and may use cannabis for symptom management. Because cannabis use increases the risk of cannabis use disorders (CUDs), we examined time trends in CUD among VHA patients with and without chronic pain, and whether these trends differed by age. From VHA electronic health records from 2005 to 2019 (∼4.3-5.6 million patients yearly), we extracted diagnoses of CUD and chronic pain conditions ( International Classification of Diseases [ ICD ]- 9-CM , 2005-2014; ICD-10-CM , 2016-2019). Differential trends in CUD prevalence overall and age-stratified (<35, 35-64, or ≥65) were assessed by any chronic pain and number of pain conditions (0, 1, or ≥2). From 2005 to 2014, the prevalence of CUD among patients with any chronic pain increased significantly more (1.11%-2.56%) than those without pain (0.70%-1.26%). Cannabis use disorder prevalence increased significantly more among patients with chronic pain across all age groups and was highest among those with ≥2 pain conditions. From 2016 to 2019, CUD prevalence among patients age ≥65 with chronic pain increased significantly more (0.63%-1.01%) than those without chronic pain (0.28%-0.47%) and was highest among those with ≥2 pain conditions. Over time, CUD prevalence has increased more among VHA patients with chronic pain than other VHA patients, with the highest increase among those age ≥65. Clinicians should monitor symptoms of CUD among VHA patients and others with chronic pain who use cannabis, and consider noncannabis therapies, particularly because the effectiveness of cannabis for chronic pain management remains inconclusive.
| S-EPMC10524371 | biostudies-literature
Project description:ObjectiveIn the United States, adult cannabis use has increased over time, but less information is available on time trends in cannabis use disorder. The authors used Veterans Health Administration (VHA) data to examine change over time in cannabis use disorder diagnoses among veterans, an important population subgroup, and whether such trends differ by age group (<35 years, 35-64 years, ≥65 years), sex, or race/ethnicity.MethodsVHA electronic health records from 2005 to 2019 (range of Ns per year, 4,403,027-5,797,240) were used to identify the percentage of VHA patients seen each year with a cannabis use disorder diagnosis (ICD-9-CM, January 1, 2005-September 30, 2015; ICD-10-CM, October 1, 2015-December 31, 2019). Trends in cannabis use disorder diagnoses were examined by age and by race/ethnicity and sex within age groups. Given the transition in ICD coding, differences in trends were tested within two periods: 2005-2014 (ICD-9-CM) and 2016-2019 (ICD-10-CM).ResultsIn 2005, the percentages of VHA patients diagnosed with cannabis use disorder in the <35, 35-64, and ≥65 year age groups were 1.70%, 1.59%, and 0.03%, respectively; by 2019, the percentages had increased to 4.84%, 2.86%, and 0.74%, respectively. Although the prevalence of cannabis use disorder was consistently higher among males than females, between 2016 and 2019, the prevalence increased more among females than males in the <35 year group. Black patients had a consistently higher prevalence of cannabis use disorder than other racial/ethnic groups, and increases were greater among Black than White patients in the <35 year group in both periods.ConclusionsSince 2005, diagnoses of cannabis use disorder have increased substantially among VHA patients, as they have in the general population and other patient populations. Possible explanations warranting investigation include decreasing perception of risk, changing laws, increasing cannabis potency, stressors related to growing socioeconomic inequality, and use of cannabis to self-treat pain. Clinicians and the public should be educated about the increases in cannabis use disorder in general in the United States, including among patients treated at the VHA.
| S-EPMC9529770 | biostudies-literature
Project description:BackgroundCannabis use disorder is associated with considerable comorbidity and impairment in functioning, and prevalence is increasing among adults with chronic pain. We aimed to assess the effect of introduction of medical cannabis laws (MCL) and recreational cannabis laws (RCL) on the increase in cannabis use disorder among patients in the US Veterans Health Administration (VHA).MethodsData from patients with one or more primary care, emergency, or mental health visit to the VHA in 2005-19 were analysed using 15 repeated cross-sectional VHA electronic health record datasets (ie, one dataset per year). Patients in hospice or palliative care were excluded. Patients were stratified as having chronic pain or not using an American Pain Society taxonomy of painful medical conditions. We used staggered-adoption difference-in-difference analyses to estimate the role of MCL and RCL enactment in the increases in prevalence of diagnosed cannabis use disorder and associations with presence of chronic pain, accounting for the year that state laws were enacted. We did this by fitting a linear binomial regression model stratified by pain, with time-varying cannabis law status, fixed effects for state, categorical year, time-varying state-level sociodemographic covariates, and patient covariates (age group [18-34 years, 35-64 years, and 65-75 years], sex, and race and ethnicity).FindingsBetween 2005 and 2019, 3 234 382-4 579 994 patients were included per year. Among patients without pain in 2005, 5·1% were female, mean age was 58·3 (SD 12·6) years, and 75·7%, 15·6%, and 3·6% were White, Black, and Hispanic or Latino, respectively. In 2019, 9·3% were female, mean age was 56·7 (SD 15·2) years, and 68·1%, 18·2%, and 6·5% were White, Black, and Hispanic or Latino, respectively. Among patients with pain in 2005, 7·1% were female, mean age was 57·2 (SD 11·4) years, and 74·0%, 17·8%, and 3·9% were White, Black, and Hispanic or Latino, respectively. In 2019, 12·4% were female, mean age was 57·2 (SD 13·8) years, and 65·3%, 21·9%, and 7·0% were White, Black, and Hispanic or Latino, respectively. Among patients with chronic pain, enacting MCL led to a 0·135% (95% CI 0·118-0·153) absolute increase in cannabis use disorder prevalence, with 8·4% of the total increase in MCL-enacting states attributable to MCL. Enacting RCL led to a 0·188% (0·160-0·217) absolute increase in cannabis use disorder prevalence, with 11·5% of the total increase in RCL-enacting states attributable to RCL. In patients without chronic pain, enacting MCL and RCL led to smaller absolute increases in cannabis use disorder prevalence (MCL: 0·037% [0·027-0·048], 5·7% attributable to MCL; RCL: 0·042% [0·023-0·060], 6·0% attributable to RCL). Overall, associations of MCL and RCL with cannabis use disorder were greater in patients with chronic pain than in patients without chronic pain.InterpretationIncreasing cannabis use disorder prevalence among patients with chronic pain following state legalisation is a public health concern, especially among older age groups. Given cannabis commercialisation and widespread public beliefs about its efficacy, clinical monitoring of cannabis use and discussion of the risk of cannabis use disorder among patients with chronic pain is warranted.FundingNIDA grant R01DA048860, New York State Psychiatric Institute, and the VA Centers of Excellence in Substance Addiction Treatment and Education.
| S-EPMC10627060 | biostudies-literature
Project description:ObjectiveCannabis use disorder diagnoses are increasing among U.S. adults and are more prevalent among people with comorbid psychiatric disorders. Recent changes in cannabis laws, increasing cannabis availability, and higher-potency cannabis may have placed people with cannabis use and psychiatric disorders at disproportionately increasing risk for cannabis use disorder. The authors used Veterans Health Administration (VHA) data to examine whether trends in cannabis use disorder prevalence among VHA patients differ by whether they have psychiatric disorders.MethodsVHA electronic health records from 2005 to 2019 (N range, 4,332,165-5,657,277) were used to identify overall and age-group-specific (<35, 35-64, and ≥65 years) trends in prevalence of cannabis use disorder diagnoses among patients with depressive, anxiety, posttraumatic stress, bipolar, or psychotic spectrum disorders and to compare these to corresponding trends among patients without any of these disorders. Given transitions in ICD coding, differences in trends were tested within two periods: 2005-2014 (ICD-9-CM) and 2016-2019 (ICD-10-CM).ResultsGreater increases in prevalence of cannabis use disorder diagnoses were observed among patients with psychiatric disorders compared to those without (difference in prevalence change, 2005-2014: 1.91%, 95% CI=1.87-1.96; 2016-2019: 0.34%, 95% CI=0.29-0.38). Disproportionate increases in cannabis use disorder prevalence among patients with psychiatric disorders were greatest among those under age 35 between 2005 and 2014, and among those age 65 or older between 2016 and 2019. Among patients with psychiatric disorders, the greatest increases in cannabis use disorder prevalences were observed among those with bipolar and psychotic spectrum disorders.ConclusionsThe findings highlight disproportionately increasing disparities in risk of cannabis use disorder among VHA patients with common psychiatric disorders. Greater public health and clinical efforts are needed to monitor, prevent, and treat cannabis use disorder in this population.
| S-EPMC10843609 | biostudies-literature
Project description:ImportanceGiven the personal and social burdens of opioid use disorder (OUD), understanding time trends in OUD prevalence in large patient populations is key to planning prevention and treatment services.ObjectiveTo examine trends in the prevalence of OUD from 2005 to 2022 overall and by age, sex, and race and ethnicity.Design, setting, and participantsThis serial cross-sectional study included national Veterans Health Administration (VHA) electronic medical record data from the VHA Corporate Data Warehouse. Adult patients (age ≥18 years) with a current OUD diagnosis (using International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] and International Statistical Classification of Diseases, Tenth Revision, Clinical Modification [ICD-10-CM] codes) who received outpatient care at VHA facilities from January 1, 2005, to December 31, 2022, were eligible for inclusion in the analysis.Main outcomes and measuresThe main outcome was OUD diagnoses. To test for changes in prevalence of OUD over time, multivariable logistic regression models were run that included categorical study year and were adjusted for sex, race and ethnicity, and categorical age.ResultsThe final sample size ranged from 4 332 165 to 5 962 564 per year; most were men (89.3%-95.0%). Overall, the annual percentage of VHA patients diagnosed with OUD almost doubled from 2005 to 2017 (0.60% [95% CI, 0.60%-0.61%] to 1.16% [95% CI, 1.15%-1.17%]; adjusted difference, 0.55 [95% CI, 0.54-0.57] percentage points) and declined thereafter (2022: 0.97% [95% CI, 0.97%-0.98%]; adjusted difference from 2017 to 2022, -0.18 [95% CI, -0.19 to -0.17] percentage points). This trend was similar among men (0.64% [95% CI, 0.63%-0.64%] in 2005 vs 1.22% [95% CI, 1.21%-1.23%] in 2017 vs 1.03% [95% CI, 1.02%-1.04%] in 2022), women (0.34% [95% CI, 0.32%-0.36%] in 2005 vs 0.68% [95% CI, 0.66%-0.69%] in 2017 vs 0.53% [95% CI, 0.52%-0.55%] in 2022), those younger than 35 years (0.62% [95% CI, 0.59%-0.66%] in 2005 vs 2.22% [95% CI, 2.18%-2.26%] in 2017 vs 1.00% [95% CI, 0.97%-1.03%] in 2022), those aged 35 to 64 years (1.21% [95% CI, 1.19%-1.22%] in 2005 vs 1.80% [95% CI, 1.78%-1.82%] in 2017 vs 1.41% [95% CI, 1.39%-1.42%] in 2022), and non-Hispanic White patients (0.44% [95% CI, 0.43%-0.45%] in 2005 vs 1.28% [95% CI, 1.27%-1.29%] in 2017 vs 1.13% [95% CI, 1.11%-1.14%] in 2022). Among VHA patients aged 65 years or older, OUD diagnoses increased from 2005 to 2022 (0.06% [95% CI, 0.06%-0.06%] to 0.61% [95% CI, 0.60%-0.62%]), whereas among Hispanic or Latino and non-Hispanic Black patients, OUD diagnoses decreased from 2005 (0.93% [95% CI, 0.88%-0.97%] and 1.26% [95% CI, 1.23%-1.28%], respectively) to 2022 (0.61% [95% CI, 0.59%-0.63%] and 0.82% [95% CI, 0.80%-0.83%], respectively).Conclusions and relevanceThis serial cross-sectional study of national VHA electronic health record data found that the prevalence of OUD diagnoses increased from 2005 to 2017, peaked in 2017, and declined thereafter, a trend primarily attributable to changes among non-Hispanic White patients and those younger than 65 years. Continued public health efforts aimed at recognizing, treating, and preventing OUD are warranted.
| S-EPMC11662256 | biostudies-literature
Project description:ImportanceDespite public health concerns that cannabis legalization may increase the number of cases of schizophrenia caused by cannabis, there is limited evidence on this topic.ObjectiveTo examine changes in the population-attributable risk fraction (PARF) for cannabis use disorder (CUD) associated with schizophrenia after liberalization of medical cannabis and legalization of nonmedical cannabis in Canada.Design, setting, and participantsThis population-based cohort study was conducted in Ontario, Canada, from January 1, 2006, to December 31, 2022, among 13 588 681 people aged 14 to 65 years without a history of schizophrenia.ExposuresDiagnosis of CUD in the emergency department or hospital setting (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Canada [ICD-10-CA] codes F12x and T40.7).Main outcome and measuresChanges in the PARF for CUD associated with schizophrenia (ICD-10-CA codes F20x and F25x and Diagnostic and Statistical Manual of Mental Disorders [Fourth Edition] [DSM-IV] code 295x) over 3 policy periods: prelegalization (January 2006 to November 2015), liberalization of medical and nonmedical cannabis (December 2015 to September 2018), and legalization of nonmedical cannabis (October 2018 to December 2022). A secondary outcome was diagnosis of psychosis not otherwise specified (NOS) (ICD-10-CA code F29x and DSM-IV code 298x). Segmented linear regression was used to examine changes after the liberalization of medical cannabis in 2015 and the legalization of nonmedical cannabis in 2018.ResultsThe study included 13 588 681 individuals (mean [SD] age, 39.3 [16.1] years; 6 804 906 males [50.1%]), of whom 118 650 (0.9%) had CUD. A total of 91 106 individuals (0.7%) developed schizophrenia (80 523 of 13 470 031 [0.6%] in the general population without CUD vs 10 583 of 118 650 [8.9%] with CUD). The PARF for CUD associated with schizophrenia almost tripled from 3.7% (95% CI, 2.7%-4.7%) during the prelegalization period to 10.3% (95% CI, 8.9%-11.7%) during the legalization period. The PARF in the postlegalization period ranged from 18.9% (95% CI, 16.8%-21.0%) among males aged 19 to 24 years to 1.8% (95% CI, 1.1%-2.6%) among females aged 45 to 65 years. The annual incidence of schizophrenia was stable over time, while the incidence of psychosis NOS increased from 30.0 to 55.1 per 100 000 individuals (83.7%) in the postlegalization period relative to the prelegalization period. The PARF for CUD associated with schizophrenia increased steadily over the study with no accelerations after cannabis policy changes, while increases in the PARF for CUD associated with psychosis NOS accelerated after medical cannabis liberalization.Conclusions and relevanceIn this cohort study of individuals aged 14 to 65 years in Ontario, Canada, the proportion of incident cases of schizophrenia associated with CUD almost tripled during a period of substantial liberalization of cannabis policy. Ongoing research is indicated to understand the long-term associations of cannabis policy with the prevalence of psychotic disorders.
| S-EPMC11795325 | biostudies-literature
Project description:IntroductionYoung adults' cannabis and alcohol use patterns have changed after state recreational cannabis legalization according to studies based on college samples but not nationally representative samples. Associations between recreational cannabis legalization and changes in cannabis and alcohol use outcomes among young adults were examined, including differences by college enrollment and minor status (ages 18-20 vs 21-23 years).MethodsRepeated cross-sectional data (2008-2019) were collected from college-eligible participants aged 18-23 years in the National Survey on Drug Use and Health. Self-reported past-month cannabis use and frequent use (≥20 days) and a proxy for past-year DSM-5 cannabis use disorder were primary outcomes; past-month frequent alcohol use and binge drinking were secondary outcomes. Multilevel logistic regression models quantified changes in outcome prevalence from the study years before to after recreational cannabis legalization, adjusting for secular trends. Analyses were conducted on March 22, 2022.ResultsPrevalence increased from before to after recreational cannabis legalization for past-month cannabis use (from 21% to 25%) and past-year proxy cannabis use disorder (from 11% to 13%); the increases were statistically significant [adjusted odds ratio (95% CI) = 1.20 (1.08-1.32) and 1.14 (1.003-1.30), respectively]. Increases were detected for young adults who were not in college and who were aged 21-23 years. Recreational cannabis legalization impacts were not detected for secondary outcomes.ConclusionsSome young adults appear sensitive to state recreational cannabis legalization, including in terms of cannabis use disorder risk. Additional prevention efforts should be directed to young adults who are not in college and timed to occur before age 21 years.
| S-EPMC10725514 | biostudies-literature
Project description:ImportanceIt is unknown whether state recreational cannabis legalization (RCL) is related to increased rates of prenatal cannabis use or whether RCL-related changes vary with cannabis screening methods or the local policy environment.ObjectiveTo test whether RCL in California was associated with changes in prenatal cannabis use rates, whether changes were evident in both self-report and urine toxicology testing, and whether rates varied by local policies banning vs allowing adult-use retailers post-RCL.Design, setting, and participantsThis population-based time-series study used data from pregnancies in Kaiser Permanente Northern California universally screened for cannabis use during early pregnancy by self-report and toxicology testing from January 1, 2012, to December 31, 2019. Analyses were conducted from September 2022 to August 2024.ExposuresCalifornia state RCL passage (November 9, 2016) and implementation of legal sales (January 1, 2018) were examined with a 1-month lag. Local policies allowing vs banning medical retailers pre-RCL and adult-use retailers post-RCL were also examined.Main outcomes and measuresAny prenatal cannabis use was based on screening at entrance to prenatal care (typically at 8-10 weeks' gestation) and defined as (1) a positive urine toxicology test result or self-report, (2) a positive urine toxicology test result, or (3) self-report. Interrupted time series models were fit using Poisson regression, adjusting for age, race and ethnicity, and neighborhood deprivation index.ResultsThe sample of 300 993 pregnancies (236 327 unique individuals) comprised 25.9% Asian individuals, 6.4% Black individuals, 26.0% Hispanic individuals, 37.7% White individuals, and 4.1% individuals of other, multiple, or unknown race, with a mean (SD) age of 30.3 (5.4) years. Before RCL implementation, rates of prenatal cannabis use rose steadily from 4.5% in January 2012 to 7.1% in January 2018. There was no change in use rates at the time of RCL passage (level change rate ratio [RR], 1.03; 95% CI, 0.96-1.11) and a statistically significant increase in rates in the first month after RCL implementation, increasing to 8.6% in February 2018 (level change RR, 1.10; 95% CI, 1.04-1.16). Results were similar when defining prenatal cannabis use by (1) a toxicology test or (2) self-report. In local policy analyses, the post-RCL implementation increase in use was only found among those in jurisdictions allowing adult-use cannabis retailers (allowed RR, 1.21; 95% CI, 1.10-1.33; banned RR, 1.01; 95% CI, 0.93-1.10).Conclusions and relevanceIn this time-series study, RCL implementation in California was associated with an increase in rates of cannabis use during early pregnancy, defined by both self-report and toxicology testing, driven by individuals living in jurisdictions that allowed adult-use retailers.
| S-EPMC11530934 | biostudies-literature
Project description:Background: The past decade has seen unprecedented shifts in the cannabis policy environment, and the public health impacts of these changes will hinge on how they affect patterns of cannabis use and the use and harms associated with other substances.Objectives: To review existing research on how state cannabis policy impacts substance use, emphasizing studies using methods for causal inference and highlighting gaps in our understanding of policy impacts on evolving cannabis markets.Methods: Narrative review of quasi-experimental studies for how medical cannabis laws (MCLs) and recreational cannabis laws (RCLs) affect cannabis use and use disorders, as well as the use of or harms from alcohol, opioids, and tobacco.Results: Research suggests MCLs increase adult but not adolescent cannabis use, and provisions of the laws associated with less regulated supply may increase adult cannabis use disorders. These laws may reduce some opioid-related harms, while their impacts on alcohol and tobacco use remain uncertain. Research on RCLs is just emerging, but findings suggest little impact on the prevalence of adolescent cannabis use, potential increases in college student use, and unknown effects on other substance use.Conclusions: Research on how MCLs influence cannabis use has advanced our understanding of the importance of heterogeneity in policies, populations, and market dynamics, but studies of how MCLs relate to other substance use often ignore these factors. Understanding effects of cannabis laws requires greater attention to differences in short- versus long-term effects of the laws, nuances of policies and patterns of consumption, and careful consideration of appropriate control groups.
| S-EPMC6934162 | biostudies-literature