Heavy Lifetime Cannabis Use and Mortality by Sex.

Importance: The association between mortality and cannabis use remains unclear. Objective: To examine sex-stratified associations of cumulative lifetime cannabis use with all-cause, cardiovascular disease (CVD), and cancer mortality in the UK Biobank population. Design, Setting, and Participants: This cohort study used data from volunteers in the UK Biobank population. Participant monitoring for mortality in the UK Biobank study commenced from the point of their inclusion between 2006 and 2010 and continued until December 19, 2020. Data regarding the causes of death were sourced from the National Health Service Information Centre. Data were analyzed from inception of study inclusion to December 2020. Exposure: Cannabis use status was assessed by questionnaire and categorized as heavy, moderate, low, and never. Main Outcomes and Measures: The main outcomes were all-cause, CVD, and cancer mortality. Sex-stratified associations of cumulative lifetime cannabis use with mortality were estimated using Cox proportional hazards regression with adjustment for demographic and clinical variables. Results: Among 121 895 participants (54.51% females with mean [SD] age of 55.15 [7.64] years; 45.49% males with mean [SD] age of 56.46 [7.79] years) during an overall median of 11.80 years (IQR, 10.53-13.22 years) of follow-up, 2375 total deaths occurred, including 1411 deaths from CVD and 440 from cancer. In males, after full adjustment, the hazard ratios (HRs) were 1.28 (95% CI, 0.90-1.81) for all-cause mortality, 0.98 (95% CI, 0.43-2.25) for CVD mortality, and 1.09 (95% CI, 0.71-1.67) for cancer mortality among heavy cannabis users compared with never users. In females, after full adjustment, the HRs were 1.49 (95% CI, 0.92-2.40) for all-cause mortality, 2.67 (95% CI, 1.19-4.32) for CVD mortality, and 1.61 (95% CI, 0.91-2.83) for cancer mortality among heavy cannabis users compared with never users. In female current tobacco users, after full adjustment, heavy cannabis use was associated with all-cause mortality (HR, 2.25; 95% CI, 1.12-4.53), CVD mortality (HR, 2.56; 95% CI, 1.43-15.36), and cancer mortality (HR, 3.52; 95% CI, 1.50-8.33) and among never tobacco users was associated with CVD mortality (HR, 2.98; 95% CI, 1.67-6.61). In male current tobacco users, heavy cannabis use was associated with cancer mortality (HR, 2.44; 95% CI, 1.14-5.23). Conclusions and Relevance: In this study, a positive association between CVD mortality and heavy lifetime cannabis use was observed among females. Longitudinal studies are needed in general populations to investigate the potential effects of cannabis on mortality.

Cannabis use and its association with psychopathological symptoms in a Swiss adult population: a cross-sectional analysis.

Background: As the most commonly used illicit substance, cannabis is gaining global acceptance through increasing legalization efforts. This shift intensifies the need for research to guide policymakers and healthcare providers in harm reduction and treatment strategies. Nonetheless, the relationship between psychopathological symptoms and cannabis use remains inadequately understood. Methods: A sample of regular cannabis consumers completed self-reported assessments for depression (Patient Health Questionnaire-9), anxiety (General Anxiety Disorder-7), Attention-Deficit/Hyperactivity Disorder (ADHD; Adult ADHD Self-Report Scale V1.1), and psychosis (Early Recognition Inventory based on IRAOS) as well as previous black-market cannabis use patterns. Cannabis Use Disorder Identification Test Revised (CUDIT-R) was used to identify cannabis use disorder (CUD). To understand psychopathological symptom load related to cannabis consumption as well as cannabis use motives, multiple regression models were performed to identify psychopathological variables predicting cannabis use frequency and quantity. Linear regression and correlation analyses were conducted, adjusting for relevant covariates (age, gender, education, alcohol, other substance use). Results: Three-hundred-sixty regular cannabis users interested in a study on regulated cannabis access in Basel, Switzerland were examined. In bivariate analysis, cannabis use frequency correlated with depressive (r(358) = 0.16, p = 0.003) and anxiety symptom load (r(358) = 0.11, p = 0.034). Cannabis quantity correlated with depressive (r(358) = 0.15, p = 0.005), ADHD (r(358) = 0.14, p = 0.008), and psychosis symptom load (r(358) = 0.16, p = 0.002). However, in the adjusted regression models only depressive and ADHD symptom loads were significantly associated with cannabis use frequency (p = 0.006 and p = 0.034, respectively) and quantity (p = 0.037 and p = 0.019, respectively). No significant correlations between cannabis consumption and anxiety or psychosis remained after adjustment. Conclusion: ADHD and depressive symptoms correlate with increased cannabis use in a cohort of regular users, suggesting potential self-medication in nonclinical populations. With the rising availability of cannabis worldwide, these results highlight the necessity for longitudinal studies to disentangle the complex dynamics between cannabis consumption and mental health symptoms.

Cannabis Use Reported by Patients Receiving Primary Care in a Large Health System.

Importance: Despite the changing legal status of cannabis and the potential impact on health, few health systems routinely screen for cannabis use, and data on the epidemiology of cannabis use, and especially medical cannabis use among primary care patients, are limited. Objective: To describe the prevalence of, factors associated with, and reasons for past-3 month cannabis use reported by primary care patients. Design, Setting, and Participants: This cross-sectional study used electronic health record data from patients aged 18 years and older who had an annual wellness visit between January 2021 and May 2023 from a primary care clinic within a university-based health system in Los Angeles, California. Exposures: Factors of interest included age, race and ethnicity, sex, employment status, and neighborhood Area Deprivation Index (ADI). Main Outcomes and Measures: Cannabis use was assessed using the Alcohol Substance Involvement Screening Test (ASSIST). Patients were also asked about reasons for use, symptoms for which they used cannabis, and mode of use. Results: Among the 175 734 patients screened, the median (range) age was 47 (18-102) years; 101 657 (58.0%) were female; 25 278 (15.7%) were Asian, 21 971 (13.7%) were Hispanic, and 51 063 (31.7%) were White. Cannabis use was reported by 29 898 (17.0%), with 10 360 (34.7%) having ASSIST scores indicative of moderate to high risk for cannabis use disorder (CUD). Prevalence of cannabis use was higher among male patients than female patients (14 939 [20.0%] vs 14 916 [14.7%]) and younger patients (18-29 years, 7592 [31.0%]; ≥60 years, 4200 [8.5%]), and lower among those who lived in the most disadvantaged neighborhoods (ADI decile 9-10, 189 [13.8%]; ADI decile 1-2, 12 431 [17.4%]). The most common modes of use included edibles (18 201 [61.6%]), smoking (15 256 [51.7%]), and vaporizing (8555 [29.0%]). While 4375 patients who reported using cannabis (15.6%) did so for medical reasons only, 21 986 patients (75.7%) reported using cannabis to manage symptoms including pain (9196 [31.7%]), stress (14 542 [50.2%]), and sleep (16 221 [56.0%]). The median (IQR) number of symptoms managed was 2 (1-4), which was higher among patients who were at moderate to high risk for CUD (4 [2-6] symptoms). Conclusions and Relevance: In this study, cannabis use and risk of CUD were common, and more than three-quarters of patients who reported any cannabis use reported doing so to manage a health-related symptom. These findings suggest that integration of information regarding cannabis use for symptom management could help provide a crucial point-of-care opportunity for clinicians to understand their patients' risk for CUD.

Cannabis use, mental health, and problematic Internet use in Quebec: A study protocol.

BACKGROUND: Problematic Internet use is characterized by excessive use of online platforms that can result in social isolation, family problems, psychological distress, and even suicide. Problematic Internet use has been associated with cannabis use disorder, however knowledge on the adult population remains limited. In Quebec, cannabis use has significatively increased since 2018, and it is associated with various risks in public safety, public health, and mental health. This study aims to identify factors associated with problematic Internet use among adult cannabis users and to better understand their experiences. METHOD: This project is a mixed explanatory sequential study consisting of two phases. Phase 1 (n = 1500) will be a cross-sectional correlational study using probability sampling to examine variables that predispose individuals to problematic Internet use, characteristics associated with cannabis use, Internet use, and the mental health profile of adult cannabis users in Quebec. Descriptive analyses and regression models will be used to determine the relationship between cannabis use and Internet use. Phase 2 (n = 45) will be a descriptive qualitative study in the form of semi-structured interviews aimed at better understanding the experience and background of cannabis users with probable problematic Internet use. DISCUSSION: The results of this study will support the development of public policies and interventions for the targeted population, by formulating courses of action that contribute to the prevention and reduction of harms associated with cannabis use and problematic Internet use. Furthermore, an integrated knowledge mobilization plan will aid in the large-scale dissemination of information that can result useful to decision-makers, practitioners, members of the scientific community, and the general population regarding the use of cannabis and the Internet.

Density of cannabis outlets vs. cannabis use behaviors and prevalent cannabis use disorder: findings from a nationally-representative survey.

Background: Thailand recently decriminalized (de facto legalized) cannabis use and sales. However, nationally representative data are scarce with regard to cannabis use behaviors and its association with cannabis outlet density. The objectives of this study are: (1) to describe the prevalence of cannabis use behaviors and cannabis use disorder among the general adult population of Thailand; (2) to describe the extent that the density of cannabis outlets is associated with cannabis use behaviors, cannabis use disorder, and the amount of cannabis smoked per day. Methods: We conducted a community-based cross-sectional study in 11 provinces and the Bangkok Metropolitan Area. Participants were residents of sampled communities aged 20 years or older. We requested literate participants to self-administer the questionnaire and interviewed participants who could not read. We analyzed data using descriptive statistics with sampling weight adjustments and multivariate logistic regression analyses. Results: The prevalence of current cannabis use was 15 percent. At a 400-m radius, participants who reported three cannabis outlets had 4.2 times higher odds of being current users than participants who reported no outlet (Adjusted OR = 4.82; 95% CI [3.04-7.63]). We found no association between outlet density and hazardous cannabis use or cannabis use disorder, nor association with the amount of cannabis use among cannabis smokers. Discussion and Conclusion: The patterns of association between outlet density and cannabis use behaviors were inconsistent. Furthermore, limitations regarding outlet density measurement and lack of temporality should be considered as caveats in the interpretation of the study findings.

Changing cannabis legislation in Canada and a longitudinal look at "regular" cannabis use in patients with eating disorders.

Regular cannabis use (CU), defined as "weekly or more often", is associated with a number of negative mental health outcomes. In the last decade, Canada legalized first medical and then recreational CU. Despite higher prevalence in mental health populations, little research has documented changes in frequency of CU with progressive legalization of cannabis. This study examined rates of CU in a sample of 843 treatment-seeking patients with eating disorders (ED) in an outpatient setting between 2004 and 2020. Across ED diagnoses, segmented regression indicated a significant break-point in regular CU in 2014, commensurate with the relaxation of medical cannabis laws. Regular CU increased from 4.9 % to 23.7 % from 2014 to 2020; well above the stable 6 % found in the general population. No significant break-point was observed in either alcohol or illicit substance use over the same time period. Significant increases in regular CU were found in patients with anorexia nervosa and binge eating disorder, while regular use remained stable in patients with bulimia nervosa. Comorbid psychiatric diagnoses did not increase odds of regular CU. Findings suggest certain patient groups with mental illness may be at risk of engaging in high frequency use in the context of legislation implying medical benefits of cannabis.

Risk-Taking, Social Support, and Belongingness Contribute to the Risk for Cannabis Use Frequency in University Students.

Background: Cannabis use and misuse is known to be associated with a variety of negative health, academic, and work-related outcomes; therefore, it is important to study the factors that contribute to or moderate its use. Objectives: The aim of this study was to determine whether risky behavior, belongingness and social support as clustering variables play a role in cannabis use frequency. Method: In a university student sample, participant data on risky behavior, belongingness and social support were used to generate vulnerability profiles through cluster analysis (low vulnerability with low risk, low vulnerability with high belonging, moderate vulnerability, and high vulnerability). Using an analysis of variance, the vulnerability profiles were compared with respect to cannabis use frequency and quantity. Through chi-square tests we assessed whether these profiles are overrepresented in certain demographics. Results: The cluster analysis yielded four groups, which differed in their vulnerability for cannabis use. The most vulnerable cluster group had higher cannabis use frequency relative to the two least vulnerable groups. Low income vs. high income was also associated with high vulnerability group membership. International students were overrepresented in the low vulnerability with high belonging group relative to the low vulnerability with low-risk group. The opposite was observed for domestic students. Conclusions: This research adds to the expanding body of literature on cannabis use and misuse in Canada, which may contribute to public health policy and the prevention and treatment of cannabis addiction by providing new insight on who may be at risk.

Improving CRNAs' Confidence and Perceived Knowledge of Endosurgical Patients Who Use Marijuana: A Quality Improvement Project.

Although some researchers have reported health-related benefits of marijuana, others have reported adverse side effects in nearly every organ system. Patterns of marijuana use are evolving, as is researchers' understanding of marijuana use for healthcare. Despite these findings and developments, nurse anesthetists are inadequately educated about marijuana's perioperative effects on endosurgical patients. As a result, many nurse anesthetists lack confidence in and knowledge of the perioperative care of endosurgical patients under the influence of marijuana. This lack of confidence and knowledge limits the ability of nurse anesthetists to provide optimal care, threatens patient safety, and potentially impairs surgical outcomes. To improve the confidence and perceived knowledge of certified registered nurse anesthetists (CRNAs) regarding perioperative care of endosurgical patients who use marijuana, a quality improvement project was conducted in a metropolitan endosurgical center in California. After the project, participating CRNAs (N = 15) reported increased confidence (z = -0.982; P = .325, > .05) and significantly improved perceived knowledge (z = -3.04; P = .002, < .05) regarding care of patients who use marijuana. For endosurgical patients who used marijuana prior to their procedure, knowledgeable and confident anesthesia care for the side effects of marijuana substantially improved the quality of care, communication, and reduced cancellations.

Nursing student stress and marijuana use.

ABSTRACT: Nursing students increasingly report being stressed. As a potential treatment, students are using marijuana, according to nursing schools. Currently, there is no standardized guideline for the use of marijuana or marijuana testing for nursing students. This article discusses several concerns about clinical nursing students' use of marijuana for stress and anxiety relief.

Age differences in patterns of cannabis use among an online US sample of adults who consume cannabis frequently.

Background: Cannabis use is increasing among middle-aged and older US adults, populations that are particularly vulnerable to the adverse effects of cannabis. Risks for adverse effects differ by cannabis use patterns, which have become increasingly heterogeneous. Nevertheless, little is known about age differences in such patterns.Objective: To investigate age differences in cannabis use patterns, comparing younger (age 18-49), middle-aged (age 50-64), and older adults (age ≥65).Methods: A total of 4,151 US adults with past 7-day cannabis consumption completed an online survey (35.1% male; 60.1% female; 4.8% identified as "other"). Regression models examined age differences in cannabis use patterns.Results: Compared to younger adults, middle-aged and older adults were more likely to consume cannabis during evening hours (50-64: adjusted odds ratio [aOR] = 2.98, 95% CI 2.24-3.96; ≥65: aOR = 4.23, 95 CI 2.82-6.35); by only one method (50-64: aOR = 1.67, 95% CI 1.34-2.09; ≥65: aOR = 3.38, 95 CI 2.24-5.09); primarily by smoking as the only method (50-64: aOR = 1.52, 95% CI 1.29-1.78; ≥65: aOR = 2.12, 95 CI 1.64-2.74); but less likely to consume concentrated cannabis products (concentrates) with extremely high %THC (50-64: aOR = 0.71, 95% CI 0.54-0.93; ≥65: aOR = 0.30, 95 CI 0.16-0.55). Age differences in cannabis use patterns were also observed between middle-aged and older adults.Conclusion: Findings suggest that middle-aged and older adults may engage in less risky cannabis use patterns compared to younger groups (e.g. lower likelihood of consuming highly potent concentrates). However, findings also underscore the importance of recognizing risks unique to these older demographics, such as smoking-related health events. Consequently, prevention strategies targeting such use patterns are needed.

Abnormal structural covariance networks in young adults with recent cannabis use.

BACKGROUND: Recent cannabis use (RCU) exerts adverse effects on the brain. However, the effect of RCU on structural covariance networks (SCNs) is still unclear. This retrospective cross-sectional study aimed to explore the effects of RCU on SCNs in young adults in terms of whole cerebral cortical thickness (CT) and cortical surface area (CSA). METHODS: A total of 117 participants taking tetrahydrocannabinol (RCU group) and 896 participants not using cannabis (control group) were included in this study. All participants underwent MRI scanning following urinalysis screening, after which FreeSurfer 5.3 was used to calculate the CT and CSA, and SCNs matrices were constructed by Brain Connectivity Toolbox. Subsequently, the global and nodal network measures of the SCNs were computed based on these matrices. A nonparametric permutation test was used to investigate the group differences by Matlab. RESULTS: Regarding global network measures of CT, young adults with RCU exhibited altered small-worldness (P = 0.020) and clustering coefficient (P = 0.031) compared to controls, whereas there were no significant group differences in terms of SCNs constructed with CSA. Additionally, SCNs based on CT and CSA displayed abnormal nodal degree, nodal efficiency, and nodal betweenness centrality in vital brain regions of the triple network, including the dorsolateral and ventrolateral prefrontal cortex, and anterior cingulate cortex. CONCLUSION: The effects of RCU on brain structure in young adults can be detected by SCNs, in which structural abnormalities in the triple network are dominant, indicating that RCU can be detrimental to brain function.

Cannabis use and mood disorders: a systematic review.

Background: Problematic cannabis use is highly prevalent among people with mood disorders. This underscores the need to understand the effects of cannabis and cannabinoids in this population, especially considering legalization of recreational cannabis use. Objectives: We aimed to (1) systematically evaluate cross-sectional and longitudinal studies investigating the interplay between cannabis use, cannabis use disorder (CUD), and the occurrence of mood disorders and symptoms, with a focus on major depressive disorder (MDD) and bipolar disorder (BD) and; (2) examine the effects of cannabis on the prognosis and treatment outcomes of MDD and BD. Methods: Following PRISMA guidelines, we conducted an extensive search for English-language studies investigating the potential impact of cannabis on the development and prognosis of mood disorders published from inception through November 2023, using EMBASE, PsycINFO, PubMed, and MEDLINE databases. Results: Our literature search identified 3,262 studies, with 78 meeting inclusion criteria. We found that cannabis use is associated with increased depressive and manic symptoms in the general population in addition to an elevated likelihood of developing MDD and BD. Furthermore, we observed that cannabis use is linked to an unfavorable prognosis in both MDD or BD. Discussion: Our findings suggest that cannabis use may negatively influence the development, course, and prognosis of MDD and BD. Future well-designed studies, considering type, amount, and frequency of cannabis use while addressing confounding factors, are imperative for a comprehensive understanding of this relationship. Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023481634.

Examining within-person associations between alcohol and cannabis use and hooking up among adolescents and young adults in the United States.

OBJECTIVE: This study examined daily associations between alcohol use, cannabis use, and simultaneous alcohol and cannabis/marijuana (SAM) use with the likelihood of hooking up (uncommitted sexual encounter that may or may not include intercourse). METHOD: We used a longitudinal measurement burst ecological momentary assessment (EMA) design with 3-week EMA bursts with daily measurements repeated quarterly across 12 months. 1,009 (57 % female, Mean age = 20.00 [SD = 3.21]) Texan adolescents and young adults ages 15-25 participated in the study. Mixed effects logistic regression models were estimated using maximum likelihood estimation to evaluate the associations between substance use and hooking up. RESULTS: Within-person results indicated that participants were more likely to hook up on days with alcohol use and on days with cannabis use, but not on days with SAM use. Participants were also more likely to hook up on drinking days with higher-than-usual alcohol use. Between-person results indicated that participants who used alcohol more often or cannabis more often on average were more likely to hook up, and participants who tended to drink more on drinking days were more likely to hook up. CONCLUSIONS: Given the significant daily-level associations between alcohol and cannabis use and hooking up behavior, public health initiatives should focus on developing interventions to reduce alcohol and cannabis use and promote safer hooking up behavior among adolescents and young adults.

Digital Interventions for Recreational Cannabis Use Among Young Adults: Systematic Review, Meta-Analysis, and Behavior Change Technique Analysis of Randomized Controlled Studies.

BACKGROUND: The high prevalence of cannabis use among young adults poses substantial global health concerns due to the associated acute and long-term health and psychosocial risks. Digital modalities, including websites, digital platforms, and mobile apps, have emerged as promising tools to enhance the accessibility and availability of evidence-based interventions for young adults for cannabis use. However, existing reviews do not consider young adults specifically, combine cannabis-related outcomes with those of many other substances in their meta-analytical results, and do not solely target interventions for cannabis use. OBJECTIVE: We aimed to evaluate the effectiveness and active ingredients of digital interventions designed specifically for cannabis use among young adults living in the community. METHODS: We conducted a systematic search of 7 databases for empirical studies published between database inception and February 13, 2023, assessing the following outcomes: cannabis use (frequency, quantity, or both) and cannabis-related negative consequences. The reference lists of included studies were consulted, and forward citation searching was also conducted. We included randomized studies assessing web- or mobile-based interventions that included a comparator or control group. Studies were excluded if they targeted other substance use (eg, alcohol), did not report cannabis use separately as an outcome, did not include young adults (aged 16-35 y), had unpublished data, were delivered via teleconference through mobile phones and computers or in a hospital-based setting, or involved people with mental health disorders or substance use disorders or dependence. Data were independently extracted by 2 reviewers using a pilot-tested extraction form. Authors were contacted to clarify study details and obtain additional data. The characteristics of the included studies, study participants, digital interventions, and their comparators were summarized. Meta-analysis results were combined using a random-effects model and pooled as standardized mean differences. RESULTS: Of 6606 unique records, 19 (0.29%) were included (n=6710 participants). Half (9/19, 47%) of these articles reported an intervention effect on cannabis use frequency. The digital interventions included in the review were mostly web-based. A total of 184 behavior change techniques were identified across the interventions (range 5-19), and feedback on behavior was the most frequently used (17/19, 89%). Digital interventions for young adults reduced cannabis use frequency at the 3-month follow-up compared to control conditions (including passive and active controls) by -6.79 days of use in the previous month (95% CI -9.59 to -4.00; P<.001). CONCLUSIONS: Our results indicate the potential of digital interventions to reduce cannabis use in young adults but raise important questions about what optimal exposure dose could be more effective, both in terms of intervention duration and frequency. Further high-quality research is still needed to investigate the effects of digital interventions on cannabis use among young adults. TRIAL REGISTRATION: PROSPERO CRD42020196959; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=196959.

Marijuana use among community-dwelling older adults: A population-based study.

OBJECTIVES: There is a paucity of population-level data on marijuana use and mental health and functioning in older adults. METHODS: We analyzed cross-sectional data (n = 910) from a well-characterized cohort, the Monongahela-Youghiogheny Healthy Aging Team (MYHAT) study. MYHAT is an age-stratified random sample of the population age 65 years and older from a small-town in the USA. Half the sample was female and half were over 75 (Mean age = 77). Most participants were non-Hispanic White. Marijuana use was assessed by self-report and symptoms of mood disorders were screened using the modified Centers for Epidemiological Studies-Depression Scale and the Generalized Anxiety Disorder screener. Cognition was assessed by the Mini-Mental State Examination and a neuropsychological test battery; functioning using the OARS Activities of Daily Living and Instrumental Activities of Daily Living; and overall assessment using the Clinical Dementia Rating (CDR®). RESULTS: One in five MYHAT participants had a history of marijuana use and 5% reported recent use, primarily for pain (41%) and recreation/relaxation (37%). Recent use was associated with cigarette and alcohol use, symptoms of depression or anxiety, and impairments in attention. CONCLUSIONS: Twenty-percent of community-dwelling older adults living in a US state where recreational marijuana use is illegal had a history of marijuana use. Recent marijuana use was less common but, consistent with prior research, associated with other substance use and poorer mental health.

Observed Trajectories of Cannabis Use and Concurrent Longitudinal Outcomes in Youth and Young Adults Receiving Coordinated Specialty Care for Early Psychosis.

Cannabis use is present and persistent in young adults with early psychosis receiving Coordinated Specialty Care (CSC) in the United States. While CSC programs are effective in improving quality of life, helping individuals reach goals, and promoting recovery, cannabis use may limit the extent of these improvements. This study extended upon previous findings to examine trajectories of cannabis use among individuals with early psychosis. The sample consisted of 1325 CSC participants enrolled for more than one year at OnTrackNY and followed up to two years, categorized into three groups: no use, reduced use, and persistent use. Baseline demographic and clinical differences were compared across groups and associations between clinical and psychosocial outcomes at 12 months and 24 months were examined across groups. Of the sample, 40 % remained persistent users over two years while 12.8 % reduced their use. At baseline, persistent users were younger (p = 0.011), more likely to be male (p < 0.001), had lower education levels (p = 0.019), and were more likely to have had past legal issues prior to admission (p < 0.001) than non-users. At 2 years, persistent users had significantly worse symptom scores than non-users (p = 0.0003) and reduced users (p = 0.0004). These findings highlight the presence of persistent cannabis use being common in this population and the need to improve substance use treatment offered to allow more CSC participants to achieve improved outcomes.