Shifts in medical cannabis use in Canada during the COVID-19 pandemic. / Changements observés au Canada dans la consommation de cannabis à des fins médicales pendant la pandémie de COVID-19.

INTRODUCTION: The COVID-19 pandemic has had widespread secondary negative health impacts including loss of material security and exacerbation of mental illness in at-risk populations. While increases in the nonmedical use of certain substances, including cannabis, have been observed in samples of the Canadian population, no research has documented COVID-concurrent shifts in medical cannabis use in Canada. METHODS: Data were derived from the 2021 Canadian Cannabis Patient Survey, an online survey administered in May 2021 to people authorized to use medical cannabis recruited from one of two Canadian licensed medical cannabis producers. McNemar tests assessed for changes in past 3-month medical cannabis frequency from before to during the pandemic. We explored correlates of increasing frequency of cannabis use since before the pandemic in bivariable and multivariable logistic models. RESULTS: In total, 2697 respondents (49.1% women) completed the survey. Daily medical cannabis use increased slightly but significantly from before the pandemic (83.2%) to during the pandemic (90.3% at time of survey; p < 0.001). Factors significantly associated with increasing frequency of medical cannabis use included female gender, younger age, pandemic-related job loss, primary cannabis use to manage mental health, prescription drug use and nonmedical cannabis use (p < 0.05). CONCLUSION: There were slight shifts towards higher frequency of medical cannabis use after the onset of the COVID-19 pandemic. While short- and long-term impacts of cannabis use on pandemic-related mental distress are unknown, clinicians working with patients who use medical cannabis should be aware of possible changes in use patterns during the pandemic.

Evaluation of Cannabis Use Among US Adults During the COVID-19 Pandemic Within Different Legal Frameworks.

This cross-sectional study analyzes the prevalence of cannabis use by US adults during the COVID-19 pandemic within different legal frameworks and evaluates differences in associated behaviors.

Healthcare practitioner perceptions on barriers impacting cannabis prescribing practices.

BACKGROUND: Canadians seeking medical cannabis (MC) may encounter difficulties in finding a healthcare provider (HCP) who authorizes their access to it. Barriers that HCPs face in authorizing MC are unclear. The objectives of this study were to evaluate HCP opinions, knowledge, comfort, and practice in MC prescribing and counseling on recreational cannabis use, and whether the COVID-19 pandemic affected MC prescribing practices. METHODS: Eligible participants included HCPs (e.g., attending physicians, nurses, pharmacists) in Canada. A questionnaire evaluating their knowledge, comfort, and practice in medical and recreational cannabis was designed based on instruments developed in previous studies. Between April 13th-December 13th 2021, ninety-one healthcare associations were asked to distribute the survey to their members, and an advertisement was placed in the online Canadian Medical Association Journal. Descriptive statistics were used to analyze the results. RESULTS: Twenty-four organizations agreed to disseminate the survey and 70 individuals completed it. Of respondents, 71% were attending physicians or medical residents, while the remainder were nurses, pharmacists or other HCPs. Almost none (6%) received training in MC in professional school but 60% did receive other training (e.g., workshops, conferences). Over half (57%) received more questions regarding MC since recreational cannabis was legalized, and 82% reported having patients who use MC. However, 56% felt uncomfortable or ambivalent regarding their knowledge of MC, and 27% were unfamiliar with the requirements for obtaining MC in Canada. The most common symptoms for recommending MC were pain and nausea, whereas the most common conditions for recommending it were cancer and intractable pain. The strongest barrier to authorizing MC was uncertainty in safe and effective dosage and routes of administration. The strongest barrier to recommending or authorizing MC was the lack of research evidence demonstrating its safety and efficacy. During the pandemic, many respondents reported that a greater number of their patients used cannabis to relieve anxiety and depression. CONCLUSIONS: Our results suggest that HCPs across Canada who responded to our survey are unfamiliar with topics related to MC. The strongest barriers appear to be lack of clinical research, and uncertainty in safe and effective MC administration. Increasing research, training, and knowledge may help HCPs feel more equipped to make informed treatment/prescribing decisions, which may help to improve access to MC.

Medical Cannabis for Gynecologic Pain Conditions: A Systematic Review.

OBJECTIVE: The endocannabinoid system is involved in pain perception and inflammation. Cannabis contains delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD), which are cannabinoids that bind to endocannabinoid system receptors. A fatty acid amide called palmitoylethanolamide (PEA) enhances endogenous cannabinoids. Given that use of medical cannabis is increasing, we sought to characterize patterns of cannabis use for gynecologic pain and its effectiveness as an analgesic. DATA SOURCES: We searched PubMed, EMBASE, Scopus, Cochrane, and ClinicalTrials.gov using terms for "woman," "cannabis," and "pain" or "pelvic pain" or "endometriosis" or "bladder pain" or "cancer." The search was restricted to English-language articles published between January 1990 and April 2021 and excluded animal studies. METHODS OF STUDY SELECTION: The initial search yielded 5,189 articles with 3,822 unique citations. Studies were included if they evaluated nonpregnant adult women who used cannabinoids for gynecologic pain conditions (eg, chronic pelvic pain, vulvodynia, endometriosis, interstitial cystitis, malignancy). Study types included were randomized controlled trials (RCTs), cohort studies, and cross-sectional studies. Covidence systematic review software was used. TABULATION, INTEGRATION, AND RESULTS: Fifty-nine studies were considered for full review, and 16 met inclusion criteria. Prevalence of cannabis use ranged from 13% to 27%. Most women ingested or inhaled cannabis and used cannabis multiple times per week, with dosages of THC and CBD up to 70 mg and 2,000 mg, respectively. Sixty-one to 95.5% reported pain relief. All six prospective cohort studies and one RCT of PEA-combination medications reported significant pain relief, and the average decrease in pain after 3 months of treatment was 3.35±1.39 on the 10-point visual analog scale. However, one fatty acid amide enzyme inhibitor RCT did not show pain reduction. CONCLUSION: Survey data showed that most women reported that cannabis improved pain from numerous gynecologic conditions. Cohort studies and an RCT using PEA-combination medications reported pain reduction. However, interpretation of the studies is limited due to varying cannabis formulations, delivery methods, and dosages that preclude a definitive statement about cannabis for gynecologic pain relief. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42021248057.

Public Health Implications of Cannabis Legalization: An Exploration of Adolescent Use and Evidence-Based Interventions.

This article examines the relaxation of state marijuana laws, changes in adolescent use of marijuana, and implications for drug education. Under federal law, use of marijuana remains illegal. In spite of this federal legislation, as of 1 June 2021, 36 states, four territories and the District of Columbia have enacted medical marijuana laws. There are 17 states, two territories and the District of Columbia that have also passed recreational marijuana laws. One of the concerns regarding the enactment of legislation that has increased access to marijuana is the possibility of increased adolescent use of marijuana. While there are documented benefits of marijuana use for certain medical conditions, we know that marijuana use by young people can interfere with brain development, so increased marijuana use by adolescents raises legitimate health concerns. A review of results from national survey data, including CDC's YRBS, Monitoring the Future, and the National Household Survey on Drug Use, allows us to document changes in marijuana use over time. Increased legal access to marijuana also has implications for educational programming. A "Reefer Madness" type educational approach no longer works (if it ever did). We explore various strategies, including prevention programs for education about marijuana, and make recommendations for health educators.

"I got a bunch of weed to help me through the withdrawals": Naturalistic cannabis use reported in online opioid and opioid recovery community discussion forums.

A growing body of research has reported on the potential opioid-sparing effects of cannabis and cannabinoids, but less is known about specific mechanisms. The present research examines cannabis-related posts in two large online communities on the Reddit platform ("subreddits") to compare mentions of naturalistic cannabis use by persons self-identifying as actively using opioids versus persons in recovery. We extracted all posts mentioning cannabis-related keywords (e.g., "weed", "cannabis", "marijuana") from December 2015 through August 2019 from an opioid use subreddit and an opioid recovery subreddit. To investigate how cannabis is discussed at-scale, we identified and compared the most frequent phrases in cannabis-related posts in each subreddit using term-frequency-inverse document frequency (TF-IDF) weighting. To contextualize these findings, we also conducted a qualitative content analysis of 200 random posts (100 from each subreddit). Cannabis-related posts were about twice as prevalent in the recovery subreddit (n = 908; 5.4% of 16,791 posts) than in the active opioid use subreddit (n = 4,224; 2.6% of 159,994 posts, p < .001). The most frequent phrases from the recovery subreddit referred to time without using opioids and the possibility of using cannabis as a "treatment." The most frequent phrases from the opioid subreddit referred to concurrent use of cannabis and opioids. The most common motivations for using cannabis were to manage opioid withdrawal symptoms in the recovery subreddit, often in conjunction with anti-anxiety and GI-distress "comfort meds," and to enhance the "high" when used in combination with opioids in the opioid subreddit. Despite limitations in generalizability from pseudonymous online posts, this examination of reports of naturalistic cannabis use in relation to opioid use identified withdrawal symptom management as a common motivation. Future research is warranted with more structured assessments that examines the role of cannabis and cannabinoids in addressing both somatic and affective symptoms of opioid withdrawal.

Changes in medical and non-medical cannabis use among United States adults before and during the COVID-19 pandemic.

Background: During the SARS-CoV-2 pandemic, cannabis dispensaries in the United States (US) reported increased sales.Objectives: This study assessed changes in cannabis use before to during the pandemic; it was hypothesized that cannabis use increased during the pandemic.Methods: A US-based survey of adults assessed patterns of use before and during the pandemic. Participants recruited via social media from 8/2020 to 9/2020 self-reported medical and non-medical cannabis use. Use was categorized as ≤ monthly, weekly, and daily/almost daily; adjusted logistic regressions determined associations between cannabis use before the pandemic with change in frequency during the pandemic.Results: Of 1,886 respondents (63% male),1,113 reported non-medical and 603 medical use of cannabis. Those reporting ≤monthly non-medical use before the pandemic had higher odds of increasing use during the pandemic than those using weekly before the pandemic (AOR 3.2 [95% CI 2.2-4.5]). Those reporting ≤ monthly and daily medical cannabis use before the pandemic had higher odds of increasing use during the pandemic than those using weekly before the pandemic (AOR 2.3 [95% 1.3, 3.9]; AOR 2.4 [95% CI 1.2, 5.1] respectively).Conclusions: The most notable increases in cannabis use during the pandemic were among those who reported using cannabis least frequently before the pandemic (two to three times odds of increased use among ≤ monthly use compared to weekly). These findings have important implications for potential health consequences related to increased cannabis use both during and after the pandemic, even in populations thought to be protected by minimal use prior to the pandemic.

Anonymized location data reveals trends in legal Cannabis use in communities with increased mental health risks at the start of the COVID-19 pandemic.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has led to increases in felt negative affect for many. This is concerning as individuals at increased risk for mental health issues are often more likely to use substances to cope with stressors. OBJECTIVES: The aim of the current study is to examine whether communities reporting an increased risk for developing mental health issues showed differential patterns of legal cannabis use as the pandemic began. A secondary goal is to examine the feasibility of using anonymized location data to uncover community consumption patterns of potential concern. METHODS: Anonymized location data from approximately 10% of devices in the United States provided a count of the number of visitors to 3,335 cannabis retail locations (medical and recreational) each day from December 1st 2019 through April 2020. Visitor counts were merged with the average number of mentally unhealthy days (aMUDs) reported in the Federal Information Processing Standard (FIPS) county the retailer was located along with FIPS county population and poverty rate estimates. A Poisson spline regression predicting visitors by day, aMUDs, as well as their interaction was performed, entering population and poverty rate as covariates. RESULTS: As the pandemic began communities reporting a greater aMUDs showed greater visitation to cannabis retailers. CONCLUSIONS: These results suggest that the COVID-19 pandemic may have led to increased legal cannabis use in at risk communities. They also highlight the value anonymized location data can provide policymakers and practitioners in uncovering community level trends as they confront an increasingly uncertain landscape.

Health and Safety in the Legal Cannabis Industry Before and During COVID-19.

In 2020, medical cannabis is legal in thirty-six states and adult use ("recreational") cannabis is legal in fifteen, despite cannabis remaining illegal at the federal level. Up to 250,000 individuals work as full-time employees in cannabis. During the COVID-19 pandemic, California, Colorado, and other states deemed medical cannabis business as essential, raising occupational challenges and safety issues for cannabis employees. In 2020, interviews were conducted with Ethan, an extraction lab assistant in Las Vegas; Haylee, a trainer with a cannabis company in Sacramento; and Belinda, a Wisconsin-based occupational health and safety trainer, to showcase concerns and experiences in cannabis workplaces and training programs. Findings from interviews reveal pro-worker activities to promote workplace safety and labor unionism while large multistate operators seek to optimize profits and obstruct workers' rights. Knowledge gained through the interviews contributes to discussions to lessen the potential exposure of the cannabis workforce to COVID 19.

The COVID-19 cannabis health study: Results from an epidemiologic assessment of adults who use cannabis for medicinal reasons in the United States.

Background: Clinical indications for medicinal cannabis include chronic conditions; thus users (MCUs) are at an increased risk of morbidity and mortality resulting from SARS-CoV-2 infection (COVID-19). The study aimed to provide data on cannabis use and self-reported behavioral changes among MCUs with preexisting chronic conditions in response to the pandemic.Methods: An internet-based questionnaire was administered to adults ≥18 who self-reported medicinal cannabis use within the past year. Data are from respondents between March 21 and April 23, 2020; response rate was 83.3%. Health conditions and cannabis frequency, route, and patterns of use were assessed via the COVID-19 Cannabis Health Questionnaire (Vidot et al. 2020).Results: Participants (N = 1202) were predominantly non-Hispanic white (82.5%) and 52.0% male (mean age 47.2 years). Mental health (76.7%), pain (43.7%), cardiometabolic (32.9%), respiratory (16.8%), and autoimmune (12.2%) conditions were most reported. Those with mental health conditions reported increased medicinal cannabis use by 91% since COVID-19 was declared a pandemic compared to those with no mental health conditions (adjusted odds ratio: 1.91, 95% CI: 1.38-2.65). 6.8% reported suspected COVID-19 symptoms. Two percent (2.1%) have been tested for COVID-19 with only 1 positive test result. Some MCUs (16%) changed their route of cannabis administration, switching to nonsmoking forms.Conclusions: The majority of MCUs reported at least one preexisting chronic health condition. Over half report fear of COVID-19 diagnosis and giving the virus to someone else; yet only some switched from smoking to nonsmoking forms of cannabis. Clinicians may consider asking about cannabis use among their patients, particularly those with chronic health conditions.

Therapeutic Cannabis and COVID-19: between opportunism and infoxication. / Cannabis terapéutico y COVID-19: entre el oportunismo y la infoxicación.

Editorial.

Editorial.