Dataset Information

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

ABSTRACT:

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.

SUBMITTER: Tolan NV

PROVIDER: S-EPMC10793079 | biostudies-literature | 2023 Apr

REPOSITORIES: biostudies-literature

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Publications

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

Tolan Nicole V NV Krasowski Matthew D MD Mathias Patrick C PC Wiencek Joesph R JR Babic Nikolina N Chai Peter R PR Chambliss Allison B AB Choucair Ibrahim I Demetriou Christiana A CA Erickson Timothy B TB Feldhammer Matthew M French Deborah D Hayes Bryan D BD Kang Phillip P El-Khoury Joe M JM Knezevic Claire E CE Monte Andrew A Nerenz Robert D RD Okorodudu Anthony O AO Roper Stephen M SM Saitman Alec A Thiriveedhi Vamsi V Uljon Sacha N SN Vest Alexis A Woodworth Alison A Yu Min M Melanson Stacy E F SEF

Clinical toxicology (Philadelphia, Pa.) 20230401 4

<h4>Background</h4>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.<h4>Methods</h4>Seventeen healthcare institutions in fifteen states (California, Colorado, Connecticut, Florida, Iowa, Kentucky, Maryland, Massachusetts, Missouri, New Hampshire, Oregon, South Carolina ...[more]

PMID: 37129223

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Project description:BackgroundCannabis is widely used in the United States despite federal laws. In US states that have progressed toward legalization, there have been various reported impacts on cannabis-related emergency department (ED) visits. However, studies on the impact of legalization in Massachusetts (MA) EDs are lacking.MethodsCannabinoid immunoassay (THC IA) results and cannabis-related ICD-10 codes were obtained for consecutive patient ED visits at two academic medical centers in Boston, MA over the following legalization periods (January 2012-December 2019): decriminalized (DEC), before medical dispensaries (MED BD), medical dispensaries available (MED DISP), before recreational dispensaries (REC BD) and recreational dispensaries available (REC DISP). Trends and monthly positivity rates for THC IA and ICD-10 codes were determined for these legalization periods.ResultsThere was an increase in both THC IA (p < .0001) and cannabis-related ICD-10 codes (p < .0001) in the ED as legalization progressed at both institutions. Positivity rates significantly increased by 7% for THC IA and 0.4% for ICD-10 codes. Increases in THC IA positivity were seen in females, patients aged 30-39, older adults (>59 years), and those in the highest income tertile. There was an increasing trend in amphetamine positivity and decreasing trend in opiate positivity in patients with positive THC IA. Unlike THC IA, significant trends per patient demographics were not seen with ICD-10 codes.ConclusionsLegalization of marijuana in MA has led to an increase in cannabis use as indicated by both increasing rates of positive THC IA results, in older adults, as well as increasing cannabis-related ICD-10 codes. Data suggest a steady increase in THC use associated with legalization that was not associated with an increase in opiate, fentanyl, or cocaine use. We recommend using ED THC IA positivity, an objective laboratory measure, to monitor THC use and the impact of state-specific progression in cannabis legalization.

Project description:ImportanceThe impact of nonmedical cannabis legalization on traffic injuries and cannabis involvement in traffic injuries is unclear.ObjectiveTo examine changes in the number and characteristics of cannabis-involved traffic injury emergency department (ED) visits from before to after legalization and subsequent commercialization (ie, increased retail store and product availability) of cannabis in Ontario, Canada.Design, setting, and participantsThis repeated cross-sectional study examined changes in cannabis- and alcohol-involved traffic injury ED visits in Ontario, Canada, during 3 time periods: prelegalization (January 2010-September 2018), legalization with product and retail store restrictions (October 2018-February 2020), and commercialization with new products and expanded number of stores, which coincided with the COVID-19 pandemic (March 2020-December 2021). All individuals aged 16 years and older eligible for Ontario's Universal Health Coverage were included. Season- and time-adjusted quasi-Poisson models were used to generate rate ratios with 95% CIs. Data were analyzed from March to April 2023.Main outcomes and measuresQuarterly counts of cannabis-involved ED visits for traffic injury.ResultsThere were 947 604 traffic injury ED visits, of which 426 (0.04%) had documented cannabis involvement and 7564 (0.8%) had documented alcohol involvement. Of the 418 individuals with documented cannabis involvement, 330 (78.9%) were male, 109 (25.6%) were aged 16 to 21 years (mean [SD] age at visit, 30.6 [12.0] years), and 113 (27.0%) had an ED visit or hospitalization for substance use in the 2 years before their traffic injury ED visit. Annual rates of cannabis-involved traffic injury ED visits increased 475.3% over the study period (0.18 visits per 1000 total motor vehicle collisions in 2010 to 1.01 in 2021). Over the same period, alcohol-involved traffic injury ED visits increased by 9.4% (8.03 in 2010 to 8.79 per 1000 traffic injury ED visits in 2021). Legalization with restrictions was associated with a 94% increase in the quarterly rate of cannabis involvement in traffic injury ED visits relative to prelegalization (adjusted rate ratio [aRR], 1.94; 95% CI, 1.37-2.75). Commercialization/COVID-19 was associated with a greater increase of 223% in rates (aRR, 3.23; 95% CI, 2.42-4.33). After adjusting for time trends before legalization, only commercialization/COVID-19 was associated with increased rates. Male sex (adjusted odds ratio [aOR], 3.38; 95% CI, 2.66-4.29), living in the lowest-income neighborhood (aOR, 1.92; 95% CI, 1.39-2.67), being aged 19 to 21 years (aOR, 4.67; 95% CI, 3.27-6.67), and having a prior cannabis-related ED visit (aOR, 8.03; 95% CI, 5.85-11.02) were all positively associated with cannabis involvement during a traffic injury ED visit.Conclusions and relevanceThis cross-sectional study found large increases in cannabis involvement in ED visits for traffic injury over time, which may have accelerated following nonmedical cannabis commercialization. Although the frequency of visits was rare, they may reflect broader changes in cannabis-impaired driving. Greater prevention efforts, including targeted education and policy measures, in regions with legal cannabis are indicated.

Project description:ImportanceRecreational cannabis legalization (RCL) has been advocated as a way to reduce the number of individuals interacting with the US criminal justice system; in theory, however, cannabis decriminalization can achieve this objective without generating the negative public health consequences associated with RCL. It is still unclear whether RCL can bring additional benefits in terms of reducing cannabis possession arrests in states that have already decriminalized cannabis.ObjectiveTo examine whether RCL was associated with changes in cannabis possession arrests in US states that had already decriminalized cannabis during the study period and whether these changes differed across age and racial subgroups.Design, setting, and participantsThis repeated cross-sectional study used cannabis possession arrest data from the Federal Bureau of Investigation Uniform Crime Reporting Program (UCRP) for US states from 2010 through 2019. Statistical analysis was conducted from October 6, 2021, to October 12, 2022.ExposuresImplementation of statewide RCL.Main outcomes and measuresCannabis possession arrest rates per 1000 population per year were assessed with a quasi-experimental difference-in-differences design and were used to estimate the association of RCL with arrest rates in RCL states that had or had not decriminalized cannabis before RCL. This association was also examined in subgroups for age (adults vs youths) and race (Black vs White).ResultsThis study included UCRP data for 31 US states, including 9 states that implemented RCL during the study period (4 without and 5 with decriminalization) and 22 non-RCL states. In the 4 states that had not decriminalized cannabis before legalization, RCL was associated with a 76.3% decrease (95% CI, -81.2% to -69.9%) in arrest rates among adults. In the 5 states that had already decriminalized cannabis, RCL was still associated with a substantial decrease in adult arrest rates (-40.0%; 95% CI, -55.1% to -19.8%). There was no association of RCL with changes in arrest rates among youths. In addition, changes in arrest rates associated with RCL did not differ among Black and White individuals.Conclusions and relevanceIn this repeated cross-sectional study, RCL was associated with a sizable reduction in cannabis possession arrests among adults in states that had already decriminalized cannabis during the study period (2010-2019), albeit the magnitude was smaller compared with states that had not decriminalized cannabis before RCL. In addition, RCL did not seem to be associated with changes in arrest rates among youths or disparities in arrest rates among Black and White individuals.

Project description:ImportanceLittle is known about changes in marijuana use and cannabis use disorder (CUD) after recreational marijuana legalization (RML).ObjectivesTo examine the associations between RML enactment and changes in marijuana use, frequent use, and CUD in the United States from 2008 to 2016.Design, setting, and participantsThis survey study used repeated cross-sectional survey data from the National Survey on Drug Use and Health (2008-2016) conducted in the United States among participants in the age groups of 12 to 17, 18 to 25, and 26 years or older.InterventionsMultilevel logistic regression models were fit to obtain estimates of before-vs-after changes in marijuana use among respondents in states enacting RML compared to changes in other states.Main outcomes and measuresSelf-reported past-month marijuana use, past-month frequent marijuana use, past-month frequent use among past-month users, past-year CUD, and past-year CUD among past-year users.ResultsThe study included 505 796 respondents consisting of 51.51% females and 77.24% participants 26 years or older. Among the total, 65.43% were white, 11.90% black, 15.36% Hispanic, and 7.31% of other race/ethnicity. Among respondents aged 12 to 17 years, past-year CUD increased from 2.18% to 2.72% after RML enactment, a 25% higher increase than that for the same age group in states that did not enact RML (odds ratio [OR], 1.25; 95% CI, 1.01-1.55). Among past-year marijuana users in this age group, CUD increased from 22.80% to 27.20% (OR, 1.27; 95% CI, 1.01-1.59). Unmeasured confounders would need to be more prevalent in RML states and increase the risk of cannabis use by 1.08 to 1.11 times to explain observed results, indicating results that are sensitive to omitted variables. No associations were found among the respondents aged 18 to 25 years. Among respondents 26 years or older, past-month marijuana use after RML enactment increased from 5.65% to 7.10% (OR, 1.28; 95% CI, 1.16-1.40), past-month frequent use from 2.13% to 2.62% (OR, 1.24; 95% CI, 1.08-1.41), and past-year CUD from 0.90% to 1.23% (OR, 1.36; 95% CI, 1.08-1.71); these results were more robust to unmeasured confounding. Among marijuana users in this age group, past-month frequent marijuana use and past-year CUD did not increase after RML enactment.Conclusions and relevanceThis study's findings suggest that although marijuana legalization advanced social justice goals, the small post-RML increase in risk for CUD among respondents aged 12 to 17 years and increased frequent use and CUD among adults 26 years or older in this study are a potential public health concern. To undertake prevention efforts, further studies are warranted to assess how these increases occur and to identify subpopulations that may be especially vulnerable.

Project description:ImportanceCannabis hyperemesis syndrome is an emerging clinical issue associated with cannabis use. Legalization of cannabis has led to an increase in vomiting-related illnesses in health care settings.ObjectiveTo examine whether legalization of cannabis in Colorado has been associated with increases in vomiting-related emergency department (ED) visits.Design, setting, and participantsA cross-sectional design was used to assess the increase in ED claims for vomiting reported to the Colorado Hospital Association between January 1, 2013, and December 31, 2018, in counties that had no prior cannabis dispensaries before legalization compared with those that did. A total of 820 778 patients seeking care through Colorado EDs were included in the analysis.ExposuresThe number of medical and recreational cannabis dispensaries per county per quarter.Main outcomes and measuresCounty per capita rate of vomiting-related ED claims per quarter.ResultsVomiting-related ED health care encounters increased from 119 312 in 2013 to 153 699 in 2018 (29% increase). Over this period, 203 861 patients (25%) were aged 0 to 18 years; 114 201 (14%) were aged 19 to 25 years, and 502 771 (61%) were aged 26 years or older; 510 584 patients (62%) were female. Additional recreational dispensaries were associated with increased vomiting-related ED visits (incidence rate ratio, 1.03; 95% CI, 1.01-1.05), but counties with high baseline medical dispensary exposure experienced smaller increases in vomiting-related ED visits than counties with no baseline medical dispensary exposure (incidence rate ratio, 0.97; 95% CI, 0.95-0.99). Counties with a high number of medical marijuana dispensaries had increases at a 5.8% slower rate than counties with none.Conclusions and relevanceThe findings of this study suggest that cannabis legalization in Colorado is associated with an increase in annual vomiting-related health care encounters with regard to exposure to these markets. It may be useful for health care clinicians to be aware of cannabis hyperemesis syndrome and inquire about cannabis use when appropriate.

Project description:ImportancePrior research suggests that the legalization of recreational cannabis is associated with increases in cannabis hyperemesis syndrome (CHS), but it is unclear how cannabis commercialization (ie, greater retail store access as well as increased variety and potency of cannabis products) may be associated with these changes.ObjectivesTo examine changes in the number and characteristics of CHS emergency department (ED) visits from before to after legalization of cannabis in Ontario, Canada.Design, setting, and participantsThis repeated cross-sectional study used interrupted time-series analyses to examine immediate and gradual changes in ED visits for CHS in Ontario, Canada, during 3 time periods: prelegalization (January 2014-September 2018), legalization with product and retail store restrictions (October 2018-February 2020), and commercialization with new products and expanded stores, which coincided with the COVID-19 pandemic (March 2020-June 2021). Data were obtained from routinely collected and linked health administrative databases. All individuals aged at least 15 years and who were eligible for Ontario's Universal Health Coverage were included. Data were analyzed between March and July 2022.Main outcomes and measuresMonthly counts of ED visits for CHS per capita.ResultsThere were 12 866 ED visits for CHS from 8140 individuals during the study. Overall, the mean (SD) age was 27.4 (10.5) years, with 2834 individuals (34.8%) aged 19 to 24 years, 4163 (51.5%) females, and 1353 individuals (16.6%) with a mental health ED visit or hospitalization in the 2 years before their first CHS ED visit. Nearly 10% of visits (1135 visits [8.8%]) led to hospital admissions. Monthly rates of CHS ED visits increased 13-fold during the 7.5-year study period, from 0.26 visits per 100 000 population in January 2014 to 3.43 visits per 100 000 population in June 2021. Legalization was not associated with an immediate or gradual change in rates of ED visits for CHS; however, commercialization during the COVID-19 pandemic period was associated with an immediate increase in rates of CHS ED visits (incidence rate ratio [IRR], 1.49; 95% CI, 1.31-1.70). During commercialization, rates of CHS ED visits increased more in women (IRR, 1.49; 95% CI, 1.16-1.92) and individuals older than the legal age of cannabis purchase (eg, age 19-24 years: IRR, 1.60; 95% CI, 1.19-2.16) than men (IRR, 1.08; 95% CI, 0.85-1.37) and individuals younger than the legal age of purchase (IRR, 0.78; 95% CI, 0.42-1.45).Conclusions and relevanceThis cross-sectional study found large increases in CHS ED visits during the period of time when the market commercialized and the COVID-19 pandemic occurred. Greater awareness of CHS symptoms by ED staff in regions where legal commercialized cannabis markets exist is indicated.

Dataset Information

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

Background

Methods

Results

Conclusions

Publications

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

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