Medical marijuana access and prolonged opioid use among adolescents and young adults.

BACKGROUND AND OBJECTIVES: Laws liberalizing access to medical marijuana are associated with reduced opioid analgesic use among adults, but little is known about the impact of such policies on adolescents and young adults. METHODS: This retrospective cohort study used 2005 to 2014 claims from MarketScan® Commercial database, which covers all 50 states and Washington D.C. The sample included 195,204 adolescent and young adult patients (aged 12-25) who underwent one of 13 surgical procedures. RESULTS: Of the 195,204 patients, 4.8% had prolonged opioid use. Several factors were associated with a higher likelihood of prolonged opioid use, including being female (adjusted odds ratio [aOR], 1.27; 95% confidence interval [CI], 1.21-1.33), longer hospital stay (aOR, 1.04; 95% CI, 1.02-1.06), greater days of index opioid supply (8-14 days: aOR, 1.39, 95% CI, 1.33-1.45; greater than 14 days: aOR, 2.42, 95% CI, 2.26-2.59), rural residence (aOR, 1.07; 95% CI, 1.01-1.14), and cholecystectomy (aOR, 1.16; 95% CI, 1.08-1.25). There was not a significant association of medical marijuana dispensary laws on prolonged opioid use (aOR, 0.98; 95% CI, 0.81-1.18). CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: Medical marijuana has been suggested as a substitute for opioids, but our results focusing on adolescents and young adults provide new evidence that this particularly vulnerable population does not exhibit reductions in prolonged use of opioids after surgery when they have legal access to medical marijuana. These findings are the first to demonstrate potentially important age differences in sustained use of opioids, and point to the need for prescriber oversight and management with this vulnerable population.

Regular Cannabis Use During the First Year of the Pandemic: Studying Trajectories Rather Than Prevalence.

INTRODUCTION: Cannabis use in the U.S. rose early in the COVID-19 pandemic, but it is unclear whether that rise was temporary or permanent. This study estimated the nature and sociodemographic correlates of U.S. adult subpopulations regularly using cannabis by examining weekly trajectories of use during the first year of the pandemic. METHODS: Data came from the Understanding America Study, a nationally representative panel of U.S. adults (N=8,397; March 10, 2020-March 29, 2021). A growth mixture model was deployed to identify subgroups with similar regular cannabis use. Sociodemographic correlates of subgroups were examined using multinomial logistic regression. RESULTS: Four cannabis-use groups were identified. Most participants did not regularly use cannabis (no regular use; 81.7%). The other groups increased regular use until April 2020 but then diverged. Some (7.1%) decreased thereafter, whereas others (3.4%) maintained their elevated use until October 26, 2020 before decreasing. The last group (7.7%) sustained their elevated use throughout. Individuals aged between 18 and 39 years, unmarried, living in poverty, without a college degree, and with longer unemployment or underemployment spells had higher odds of being in the other groups with more weekly use than in the no-regular-use group. CONCLUSIONS: The analyses revealed population subgroups with prolonged regular cannabis use and a disproportionate concentration of socioeconomically vulnerable members of society in these subgroups. These findings elucidate important heterogeneity in the subpopulations using cannabis, highlighting the urgent need to tailor public health programs for subgroups that may have unique service needs.

Mental Health Conditions and Substance Use Disorders Among Youth Subsequently Diagnosed With Opioid Use Disorder or Opioid Poisoning.

PURPOSE: This study examined receipt of services for mental health conditions and non-opioid substance use disorders (SUDs) among privately insured adolescents and young adults (ie, youth) with subsequent clinically diagnosed opioid use disorder (OUD) or opioid poisoning. METHODS: Among individuals aged 12 to 25 years (N = 4926), healthcare service utilization claims for the 2 years before a newly clinically diagnosed OUD or opioid poisoning were assessed for mental health and nonopioid SUD service visits. RESULTS: Over half (60.6%) of the youth with clinically diagnosed OUD or opioid poisoning received mental health or nonopioid SUD services in the 2 years before the opioid poisoning or OUD diagnosis. CONCLUSION: Many adolescents and young adults with clinically diagnosed OUD or opioid poisoning interacted with the healthcare system to receive services for mental health conditions and nonopioid SUDs before the OUD or opioid poisoning being diagnosed. Opportunities exist to design better intervention strategies to prevent OUD or opioid poisoning among adolescents and young adults.

A Transitioning Epidemic: How The Opioid Crisis Is Driving The Rise In Hepatitis C.

The hepatitis C virus is responsible for more deaths in the United States than any other infectious disease, and hepatitis C infections have been rising at an alarming rate since 2010. We evaluated the role of the opioid epidemic and, in particular, the 2010 introduction of an abuse-deterrent version of OxyContin. The OxyContin reformulation led some users of the drug to switch to heroin, which could have exposed them to the hepatitis C virus. We used difference-in-differences methods, using data for the period 2004-15, to assess whether states with higher rates of OxyContin misuse prior to reformulation-states where the reformulation had more impact-experienced faster growth in infections after the reformulation. States with above-median OxyContin misuse before the reformulation experienced a 222 percent increase in hepatitis C infection rates in the post-reformulation period, while states with below-median misuse experienced only a 75 percent increase. These results suggest that interventions to deter opioid misuse can have unintended long-term public health consequences.

Marijuana buyers in the United States, 2010-2014.

BACKGROUND: Obtaining or purchasing marijuana in the U.S. can be done only in certain states via a lawful market for medical or non-medical (recreational) purposes, or via an unlawful market ("black market") by home cultivation and unlicensed vendors and individuals. Given the evolving U.S. state marijuana legislation landscape, the objective of this study is to describe individuals who report buying marijuana in the past year by selected characteristics and U.S. geographical location. METHODS: Using data from the 2010-2014 National Survey on Drug Use and Health (NSDUH), we conducted bivariate chi-square tests to examine sociodemographic and selected behavioral indicators associated with buying marijuana and analyzed these factors in a multivariable logistic regression model. NSDUH participants were the noninstitutionalized civilian population aged 12+ (approximately 62,100 individuals per year) who reported using marijuana in the past year (approximately 12,400 annual average). RESULTS: A weighted estimate of approximately 18.5 million individuals aged 12+ reported buying marijuana in the past year (59% of marijuana users). Overall, buyers of marijuana were more likely to be male, report using marijuana for a greater number of days, and to meet the criteria for substance use disorder and marijuana dependence. Data showed differences of proportion of marijuana buyers by state of residence. CONCLUSIONS: Given recent changes in state laws and policies and the increased demand for marijuana products, continued monitoring of the U.S. marijuana market in coming years is important in order to understand consumption and buying patterns among at-risk segments of the population, especially youth.

Did the dependent coverage expansion increase risky substance use among young adults?

BACKGROUND: The dependent coverage expansion (DCE) enacted through the Affordable Care Act increased health insurance coverage among young adults. Increasing insurance coverage in this age group has the potential for unintended consequences on risky substance use. METHODS: Repeated cross-sectional surveys were used to compare change in substance use during the period the DCE was implemented in the 19-25year old target age group (Pre-DCE n=15,772, Post-DCE n=22,719) with contemporaneous change in a slightly older age group that was not targeted by the policy (Pre-DCE=19,851, Post-DCE n=28,157). Outcomes include 11 measures of alcohol, illicit drug and cigarette use. Statistical controls were included for demographic and socioeconomic factors and for early initiation of substance use to adjust for historical trends in developmental trajectories. RESULTS: Risky substance use decreased in young adults relative to the older age group over the period that the DCE was implemented. However, statistical adjustment for initiation of substance use prior to age 18, which is prior to exposure to the DCE, accounted for the differences between the age groups. In adjusted models, associations between the DCE and substance use outcomes range from 0.96 to 1.08 with p-values ranging from 0.330 to 0.963. CONCLUSIONS: Historical trends in initiation of substance use prior to age 18, not the DCE, account for change in risky substance use among 19-25year olds relative to 26-34year olds. The evidence does not support the suggestion that health insurance coverage would increase risky substance use among young adults.

Policies related to opioid agonist therapy for opioid use disorders: The evolution of state policies from 2004 to 2013.

BACKGROUND: State Medicaid policies play an important role in Medicaid enrollees' access to and use of opioid agonists, such as methadone and buprenorphine, in the treatment of opioid use disorders. Little information is available, however, regarding the evolution of state policies facilitating or hindering access to opioid agonists among Medicaid enrollees. METHODS: During 2013-2014, we surveyed state Medicaid officials and other designated state substance abuse treatment specialists about their state's recent history of Medicaid coverage and policies pertaining to methadone and buprenorphine. We describe the evolution of such coverage and policies and present an overview of the Medicaid policy environment with respect to opioid agonist therapy from 2004 to 2013. RESULTS: Among our sample of 45 states with information on buprenorphine and methadone coverage, we found a gradual trend toward adoption of coverage for opioid agonist therapies in state Medicaid agencies. In 2013, only 11% of states in our sample (n = 5) had Medicaid policies that excluded coverage for methadone and buprenorphine, whereas 71% (n = 32) had adopted or maintained policies to cover both buprenorphine and methadone among Medicaid enrollees. We also noted an increase in policies over the time period that may have hindered access to buprenorphine and/or methadone. CONCLUSIONS: There appears to be a trend for states to enact policies increasing Medicaid coverage of opioid agonist therapies, while in recent years also enacting policies, such as prior authorization requirements, that potentially serve as barriers to opioid agonist therapy utilization. Greater empirical information about the potential benefits and potential unintended consequences of such policies can provide policymakers and others with a more informed understanding of their policy decisions.

Growth In Buprenorphine Waivers For Physicians Increased Potential Access To Opioid Agonist Treatment, 2002-11.

Opioid use disorders are a significant public health problem, affecting two million people in the United States. Treatment with buprenorphine, methadone, or both is predominantly offered in methadone clinics, yet many people do not receive the treatment they need. In 2002 the Food and Drug Administration approved buprenorphine for prescription by physicians who completed a course and received a waiver from the Drug Enforcement Administration, exempting them from requirements in the Controlled Substances Act. To determine the waiver program's impact on the availability of opioid agonist treatment, we analyzed data for the period 2002-11 to identify counties with opioid treatment shortages. We found that the percentage of counties with a shortage of waivered physicians fell sharply, from 98.9 percent in 2002 to 46.8 percent in 2011. As a result, the percentage of the US population residing in what we classified as opioid treatment shortage counties declined from 48.6 percent in 2002 to 10.4 percent in 2011. These findings suggest that the increase in waivered physicians has dramatically increased potential access to opioid agonist treatment. Policy makers should focus their efforts on further increasing the number and geographical distribution of physicians, particularly in more rural counties, where prescription opioid misuse is rapidly growing.

More choice in health insurance marketplaces may reduce the value of the subsidies available to low-income enrollees.

Federal subsidies available to enrollees in health insurance Marketplaces are pegged to the premium of the second-lowest-cost silver plan available in each rating area (as defined by each state). People who qualify for the subsidy contribute a percentage of their income to purchase coverage, and the federal government covers the remaining cost up to the price of that premium. Because the number of plans offered and plan premiums vary substantially across rating areas, the effective value of the subsidy may vary geographically. We found that the availability of more plans in a rating area was associated with lower premiums but higher deductibles for enrollees in the second-lowest-cost silver plan. In rating areas with more than twenty plans, the average deductible in the second-lowest-cost silver plan was nearly $1,000 higher than it was in rating areas with fewer than thirteen plans. Because premium costs for second-lowest-cost silver plans are capped, deductibles may be a more salient measure of plan value for enrollees than premiums are. Greater standardization of plans or an alternative approach to calculating the subsidy could provide a more consistent benefit to enrollees across various rating areas.

Assessing the effects of medical marijuana laws on marijuana use: the devil is in the details.

This paper sheds light on previous inconsistencies identified in the literature regarding the relationship between medical marijuana laws (MMLs) and recreational marijuana use by closely examining the importance of policy dimensions (registration requirements, home cultivation, dispensaries) and the timing of when particular policy dimensions are enacted. Using data from our own legal analysis of state MMLs, we evaluate which features are associated with adult and youth recreational and heavy use by linking these policy variables to data from the Treatment Episode Data Set (TEDS) and National Longitudinal Survey of Youth (NLSY97). We employ differences-in-differences techniques, controlling for state and year fixed effects, allowing us to exploit within-state policy changes. We find that while simple dichotomous indicators of MML laws are not positively associated with marijuana use or abuse, such measures hide the positive influence legal dispensaries have on adult and youth use, particularly heavy use. Sensitivity analyses that help address issues of policy endogeneity and actual implementation of dispensaries support our main conclusion that not all MML laws are the same. Dimensions of these policies, in particular legal protection of dispensaries, can lead to greater recreational marijuana use and abuse among adults and those under the legal age of 21 relative to MMLs without this supply source.

An Epidemiological Model for Examining Marijuana Use over the Life Course.

Trajectories of drug use are usually studied empirically by following over time persons sampled from either the general population (most often youth and young adults) or from heavy or problematic users (e.g., arrestees or those in treatment). The former, population-based samples, describe early career development, but miss the years of use that generate the greatest social costs. The latter, selected populations, help to summarize the most problematic use, but cannot easily explain how people become problem users nor are they representative of the population as a whole. This paper shows how microsimulation can synthesize both sorts of data within a single analytical framework, while retaining heterogeneous influences that can impact drug use decisions over the life course. The RAND Marijuana Microsimulation Model is constructed for marijuana use, validated, and then used to demonstrate how such models can be used to evaluate alternative policy options aimed at reducing use over the life course.

What does it mean to decriminalize marijuana? A cross-national empirical examination.

Although frequently discussed as a singular policy, there is tremendous variation in the laws and regulations surrounding so-called decriminalization policies adopted by Western countries, with many jurisdictions adopting depenalization policies rather than policies that actually change the criminal status of cannabis possession offences. This paper provides a discussion of the liberalization policies being adopted in Western countries, highlighting distinct elements about particular policies that are important for proper analysis and interpretation of the policies. It then discusses some of the environmental factors that also shape these policies, and hence influence their potential impact, using data from the U.S.A. as a particular example. The results clearly show that researchers should be careful conducting intra- or international comparisons of policies because important aspects of these policies are frequently ignored.