Are Canadian Cannabis Dispensaries Counselling Pregnant Women Appropriately?

Our objective was to examine the recommendations that Canadian dispensary employees are giving to women regarding cannabis use for nausea and vomiting of pregnancy (NVP) since the legalization of recreational cannabis in 2018. We conducted a nationwide cross-sectional study of licensed cannabis dispensaries in 2019, wherein a mystery caller stated they were 8 weeks pregnant and experiencing nausea and vomiting and asked for recommendations about cannabis. Our research was modeled after the primary study done in Colorado by Dickson and colleagues in 2018. An overwhelming majority of dispensaries (93%) in our study recommended against the use of a cannabis product for NVP, which contrasted significantly to the findings of the Colorado study, in which 70% of dispensaries recommended a cannabis product. These findings suggest that Canadian dispensary employees have been adequately educated about the dangers of cannabis use during pregnancy and are helpful from a public health lens.

Medical cannabis in the UK: From principle to practice.

BACKGROUND: In the UK, medical cannabis was approved in November 2018, leading many patients to believe that the medicine would now be available on the NHS. Yet, to date, there have been only 12 NHS prescriptions and less than 60 prescriptions in total. In marked contrast, a recent patient survey by the Centre for Medical Cannabis (Couch, 2020) found 1.4 m people are using illicit cannabis for medical problems. AIMS: Such a mismatch between demand and supply is rare in medicine. This article outlines some of the current controversies about medical cannabis that underpin this disparity, beginning by contrasting current medical evidence from research studies with patient-reported outcomes. OUTCOMES: Although definite scientific evidence is scarce for most conditions, there is significant patient demand for access to medical cannabis. This disparity poses a challenge for prescribers, and there are many concerns of physicians when deciding if, and how, to prescribe medical cannabis which still need to be addressed. Potential solutions are outlined as to how the medical profession and regulators could respond to the strong demand from patients and families for access to medical cannabis to treat chronic illnesses when there is often a limited scientific evidence base on whether and how to use it in many of these conditions. CONCLUSIONS: There is a need to maximise both clinical research and patient benefit, in a safe, cautious and ethical manner, so that those patients for whom cannabis is shown to be effective can access it. We hope our discussion and outlines for future progress offer a contribution to this process.

Exploring medicinal use of cannabis in a time of policy change in New Zealand.

AIMS: To explore patterns of medicinal cannabis use prior to implementation of the new Medicinal Cannabis Scheme (MCS) in New Zealand. METHODS: An anonymous online convenience survey of 3,634 last-year medicinal users of cannabis promoted via Facebook™ from May to August 2019. RESULTS: Fifty percent of the sample were female, 18% were Maori and the median age was 38 years. The medical conditions for which cannabis was most often used were pain (81%), sleep (66%) and mental health conditions (64%). Respondents perceived cannabis to be an effective therapy and reported reducing use of other pharmaceutical medicines. Fifty-two percent reported side effects from cannabis use, including increased appetite (29%), drowsiness (12%), eye irritation (11%), dependency (10%), memory impairment (10%) and lack of energy (9%). Smoking was the dominant route of administration. Nearly half (47%) had discussed their use of cannabis with a medical professional in the previous year, while 14% had requested a prescription and 5% accessed a prescribed cannabis-based product (mostly oral CBD). CONCLUSION: Respondents self-medicated with cannabis to treat a wide range of health complaints. Only half discussed medicinal cannabis use with their medical professional, and a minority requested a prescription and used a prescribed cannabis-based product.

The impacts of potency, warning messages, and price on preferences for Cannabis flower products.

BACKGROUND: Recreational cannabis has been legalized in 11 states and Washington DC in the US. However, little is known about individual preferences for legal cannabis products. This study estimated the impacts of tetrahydrocannabinol (THC), cannabidiol (CBD), warning messages, and price on preferences for cannabis flowers. METHODS: A cross-sectional online survey with discrete choice experiments was implemented in October 2017. A sample of 2400 adults aged 21 years or older were recruited from 6 US states with recreational cannabis legalization, consisting of 1200 past-year nonusers and 1200 past-year users. Each respondent was randomly assigned to 12 discrete choice scenarios, each asking them to choose from an opt-out option and 3 cannabis flower products with varying levels in THC, CBD, warning messages, and price. The impacts of product attributes on individual choices were analyzed with nested logit regressions. RESULTS: Both cannabis nonusers and users preferred higher CBD and lower price. Users also preferred higher THC. The results on warning messages were mixed: graphic warning on drugged driving and text warning message had positive impacts on nonusers' and users' preferences for cannabis flowers, respectively, whereas FDA disapproval disclaimer had negative impacts on nonusers' preferences. Heterogeneities in preferences were revealed among nonusers by former use status and among users by reason of use. Particularly, medical cannabis users were not as responsive to THC as recreational cannabis users or dual users were. Regarding relative importance of the attributes, all respondents but medical cannabis users perceived price as the most important attribute (relative importance 51-64%), whereas medical cannabis users perceived CBD as the most important attribute (relative importance 47%). CONCLUSION: The findings indicated that product characteristics may have influences on US adults' choices of legal cannabis flower products and may deserve consideration for cannabis regulatory framework.

Density of Medical Marijuana Dispensaries and Current Marijuana Use among Young Adult Marijuana Users in Los Angeles.

Background: While tobacco and alcohol studies have focused on density of outlets as a determinant of consumption, research has begun examining the effects of medical marijuana (MM) dispensaries on marijuana use. Objectives: Examine the relationship between density of MM dispensaries and frequency of marijuana use among young adult medical marijuana patients (MMP) and nonpatient users (NPU). Methods: Young adult marijuana users (n = 329) aged 18- to 26-year old were sampled in Los Angeles in 2014-2015 and separated into MMP (n = 198) and NPU (n = 131). In 2014, 425 operational MM dispensaries were identified within the City of Los Angeles. Sequential multilevel Poisson random effect models examined density of MM dispensaries per square mile and 90 d marijuana use among MMP and NUP at the ZIP code level while controlling for demographic, behavioral, and community characteristics. Results: Density of MM dispensaries was not related to 90 d use of marijuana (days of use or hits per day) among either MMP or NPU. MMP reported significantly greater days of marijuana use in the past 90 d compared to NPU but no differences were found for hits per day. African-Americans reported significantly greater hits per day compared to whites. Hispanics reported significantly fewer hits per day compared to non-Hispanics. Conclusion: Concentration of MM dispensaries surrounding young adult marijuana users in Los Angeles was unrelated to days of marijuana use irrespective of having a MM recommendation or not. Rather, individual factors related to consumer choices and behaviors were more important in determining recent marijuana use among MMP and NPU.

A cross-sectional examination of choice and behavior of veterans with access to free medicinal cannabis.

Background: With a rise in public pressure to increase veteran access to medicinal cannabis, free cannabis collectives for military veterans are proliferating across the US. Objectives: The aim of the current study was to document which cannabis formulations and routes of administration are chosen by veterans with increased access to cannabis, and to determine whether cannabis is being used as a substitute for other licit and illicit drugs. Method: The current study collected cross-sectional self-report data on cannabis use, cannabinoid constituent composition, primary indication of use, and substitution practices among a sample of 93 US military veterans (84.9% male) with access to free cannabis. Result: Most of the sample reported using cannabinoids as a substitute for either alcohol, tobacco, prescription medications, or illicit substances, reported that they use cannabis frequently (Modal frequency >4x/day, Modal quantity = 5 to 8 grams/week), and primarily select higher-risk cannabis formulations (i.e., high THC/low CBD, smoked). The majority of the sample reported that they use cannabis to self-treat multiple physical and mental health conditions/symptoms. Conclusions: Results of the current study suggest that military Veterans with reduced barriers to access cannabis could be making both helpful and harmful choices regarding their cannabis use. These findings suggest that more guidance on the selection of cannabis-based products in this population is warranted, particularly as barriers to medicinal cannabis access are reduced.

Who's Buying What and How Much? Correlates of Purchase Behaviors From Medical Marijuana Dispensaries in Los Angeles, California.

Venue-based distribution of marijuana has become the normative model in the United States to obtain marijuana. This study examines one-time purchase behaviors at medical marijuana dispensaries (MMDs) to identify potential venue- and individual-level targets for prevention. We used a two-stage, venue-based sampling approach to randomly select patrons exiting 16 MMDs in Los Angeles, California during the spring of 2013. Patrons (N = 595) reported their discrete purchase behaviors during their most recent visit to the sampled MMD. We used hierarchical linear modeling to examine the amount spent on marijuana products, regressed on characteristics of the sampled dispensaries and their patrons. We used hierarchical generalized linear modeling to examine the likelihood of purchasing specific types of marijuana products and total grams of loose-leaf buds purchased. Patrons spent US$41.73 on average, with a range of $0-$330. We observed significant variation in purchase behaviors across MMDs and associations between venues located within high median income census tracts and a higher total amount spent and lower odds of purchasing only loose-leaf buds. The networked distance between a patron's home and the sampled MMD was positively associated with the total amount spent and total quantity of buds purchased. We also found significant relationships between medical conditions reported for use in three models: total amount spent, purchase of pre-rolled joints, and total grams of buds purchased. Policy makers may want to explore regulating the availability of specialty items that may be attractive to naïve users, such as pre-rolled joints or edibles, or high-concentration products that may be sought out by regular, heavy users.

Medical Marijuana Availability, Price, and Product Variety, and Adolescents' Marijuana Use.

PURPOSE: We aimed to examine the availability of medical marijuana dispensaries, price of medical marijuana products, and variety of medical marijuana products in school neighborhoods and their associations with adolescents' use of marijuana and susceptibility to use marijuana in the future. METHODS: A representative sample of 8th, 10th, and 12th graders (N = 46,646) from 117 randomly selected schools in California participated in the cross-sectional 2015-2016 California Student Tobacco Survey (CSTS). Characteristics of medical marijuana dispensaries in California were collected and combined with school locations to compute availability, price, and product variety of medical marijuana in school neighborhoods. Multilevel logistic regressions with random intercepts at school level were conducted to test the associations, accounting for individual and school socioeconomic characteristics. RESULTS: The distance from school to the nearest medical marijuana dispensary (within 0- to 1-mi and 1- to 3-mi bands) was not associated with adolescents' use of marijuana in the past month or susceptibility to use marijuana in the future, nor was the weighted count of medical marijuana dispensaries within the 3-mi band of school. Neither the product price nor the product variety in the dispensary nearest to school was associated with marijuana use or susceptibility to use. The results were robust to different specifications of medical marijuana measures. CONCLUSIONS: There was no evidence supporting the associations of medical marijuana availability, price, or product variety around school with adolescents' marijuana use and susceptibility to use.

The geography of crime and violence surrounding tobacco shops, medical marijuana dispensaries, and off-sale alcohol outlets in a large, urban low-income community of color.

Tobacco shops, medical marijuana dispensaries (MMD), and off-sale alcohol outlets are legal and prevalent in South Los Angeles, California-a high-crime, low-income urban community of color. This research is the first to explore the geographic associations between these three legal drug outlets with surrounding crime and violence in a large low-income urban community of color. First, spatial buffer analyses were performed using point-location and publically accessible January-December 2014 crime data to examine the geography of all felony property and violent crimes occurring within 100, 200, 500, and 1000-foot buffers of these three legal drug outlet types across South Los Angeles. Next, spatial regression analyses explored the geographic associations between density of these outlets and property and violent crimes at the census tract level. Results indicated that mean property and violent crime rates within 100-foot buffers of tobacco shops and alcohol outlets-but not MMDs-substantially exceeded community-wide mean crime rates and rates around grocery/convenience stores (i.e., comparison properties licensed to sell both alcohol and tobacco). Spatial regression analyses confirmed that tobacco shops significantly positively associated with property and violent crimes after controlling for key neighborhood factors (poverty, renters, resident mobility, ethnic/racial heterogeneity). Thus, study findings provide the first empirical evidence that tobacco shops may constitute public health threats that associate with crime and violence in U.S. low-income urban communities of color. Implementing and enforcing control policies that regulate and monitor tobacco shops in these communities may promote community health by improving public safety.

Availability and approval of cannabis-based medicines for chronic pain management and palliative/supportive care in Europe: A survey of the status in the chapters of the European Pain Federation.

BACKGROUND: There is considerable public and political interest in the use of cannabis products for medical purposes. METHODS: The task force of the European Pain Federation (EFIC) conducted a survey with its national chapters representatives on the status of approval of all types of cannabis-based medicines, the covering of costs and the availability of a position paper of a national medical association on the use of medical cannabis for chronic pain and for symptom control in palliative/supportive care. RESULTS: Thirty-one out of 37 contacted councillors responded. Plant-derived tetrahydrocannabinol/cannabidiol (THC/CBD) oromucosal spray is approved for spasticity in multiple sclerosis refractory to conventional treatment in 21 EFIC chapters. Plant-derived THC (dronabinol) is approved for some palliative care conditions in four EFIC chapters. Synthetic THC analogue (nabilone) is approved for chemotherapy-associated nausea and vomiting refractory to conventional treatment in four EFIC chapters'. Eight EFIC chapters' countries have an exceptional and six chapters an expanded access programme for medical cannabis. German and Israeli pain societies recommend the use of cannabis-based medicines as third-line drug therapies for chronic pain within a multicomponent approach. Conversely, the German medical association and a team of finish experts and officials do not recommend the prescription of medical cannabis due to the lack of high-quality evidence of efficacy and the potential harms. CONCLUSIONS: There are marked differences between the countries represented in EFIC in the approval and availability of cannabis-based products for medical use. EFIC countries are encouraged to collaborate with the European Medicines Agency to publish a common document on cannabis-based medicines. SIGNIFICANCE: There are striking differences between European countries in the availability of plant-derived and synthetic cannabinoids and of medical cannabis for pain management and for symptom control in palliative care and in the covering of costs by health insurance companies or state social security systems.

Structural barriers in access to medical marijuana in the USA-a systematic review protocol.

BACKGROUND: There are 43 state medical marijuana programs in the USA, yet limited evidence is available on the demographic characteristics of the patient population accessing these programs. Moreover, insights into the social and structural barriers that inform patients' success in accessing medical marijuana are limited. A current gap in the scientific literature exists regarding generalizable data on the social, cultural, and structural mechanisms that hinder access to medical marijuana among qualifying patients. The goal of this systematic review, therefore, is to identify the aforementioned mechanisms that inform disparities in access to medical marijuana in the USA. METHODS: This scoping review protocol outlines the proposed study design for the systematic review and evaluation of peer-reviewed scientific literature on structural barriers to medical marijuana access. The protocol follows the guidelines set forth by the Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) checklist. DISCUSSION: The overarching goal of this study is to rigorously evaluate the existing peer-reviewed data on access to medical marijuana in the USA. Income, ethnic background, stigma, and physician preferences have been posited as the primary structural barriers influencing medical marijuana patient population demographics in the USA. Identification of structural barriers to accessing medical marijuana provides a framework for future policies and programs. Evidence-based policies and programs for increasing medical marijuana access help minimize the disparity of access among qualifying patients.

Evaluating the Change in Medical Marijuana Dispensary Locations in Los Angeles Following the Passage of Local Legislation.

In May 2013, Los Angeles voters approved Proposition D, a regulatory measure that set zoning restrictions and capped the number of dispensaries at those that opened before 2007. Specifically, Proposition D stated that only 135 dispensaries were allowed to be in operation and set zoning restrictions prohibiting dispensaries from operating in certain areas. We first assessed whether the legislation changed the physical availability of medical marijuana via dispensaries in Los Angeles. We then used two data points 1 year prior to and 1 year following the implementation of Proposition D to determine if the locations of where the dispensaries are located changed after the enactment of Proposition D. Using a cross-sectional, ecological design, we investigated the change in dispensaries from 2012 to 2014 for Census tracts within the city of Los Angeles (N = 1000). We analyzed data using spatial error regression models that included controls for spatial autocorrelation due to the spatial structure of the data. We found that while the total number of dispensaries in Los Angeles remained largely unchanged, the spatial distribution of dispensaries did change in meaningful ways. Census tracts with more dispensaries in 2014 were significantly and positively associated with the proportion of African American residents and negatively associated with the percent of area that was commercially zoned. In other words, dispensaries opened in areas with a higher proportion of Black residents and closed in Census tract areas that had a higher percentage of commercially zoned land. Findings from this study highlight the importance of continuously regulating dispensary locations. Results suggest that likely as a result of changing regulations, dispensaries may be attempting to conceal their presence and locate in areas that will not advocate against their presence.

Place over traits? Purchasing edibles from medical marijuana dispensaries in Los Angeles, CA.

OBJECTIVES: To examine discrete purchasing behaviors of marijuana-infused edibles from medical marijuana dispensaries with the aim to identify potential venue- and individual-level targets for prevention. METHODS: Two-stage, venue-based sampling approach was used to randomly select patrons exiting 16 medical marijuana dispensaries in Los Angeles, California during Spring 2013. Hierarchical generalized linear modeling was used to examine the likelihood of purchasing edibles among 524 patrons reporting a discrete purchase regressed on characteristics of the sampled dispensaries and their patrons. RESULTS: At a venue level, patrons were more likely to purchase edibles from dispensaries located within Census tracts with higher median incomes or in close proximity to a higher number of dispensaries. At an individual level, patrons who identified as Black or Hispanic were associated with a lower likelihood of purchasing edibles when compared to patrons who identified as other non-White, non-Hispanic race/ethnicity. CONCLUSIONS: Place-based policies focused on regulating edible sales through dispensaries may be fruitful in influencing access to edibles. Additionally, social marketing campaigns may benefit from targeting both locations where edible purchases are more likely and populations who are more likely to purchase edibles.

The clinical implications of legalizing marijuana: Are physician and non-physician providers prepared?

INTRODUCTION: Passage of voter-driven marijuana reform laws signals a shift in public attitudes for marijuana use. For providers, legalization may necessitate practice modifications, particularly regarding patient-provider conversations about use and risk. We examined healthcare providers' knowledge of marijuana laws and health implications, professional practice behaviors, and attitudes about training. MATERIALS AND METHODS: We surveyed 114 Colorado-based providers who care for children, adolescents, pregnant and breastfeeding women using a Venue-Day-Time survey methodology throughout Colorado. The survey captured providers' (e.g., physicians, nurses, medical assistants) knowledge of state marijuana laws, risk perceptions, counseling practices, and continued training needs. RESULTS: Providers were knowledgeable about marijuana laws, cautious supporting legalization, and perceived moderate to high risks, particularly for certain groups. About 50% of providers working with adolescents and pregnant or breastfeeding women assessed marijuana use "every" or "most" visits; 23% of those working with children reported such behavior. Conversations about specific risks varied between groups. Few providers felt completely knowledgeable about marijuana health risks and lacked confidence talking to patients about this issue. CONCLUSIONS: Providers frequently assess patients' marijuana use; however, they are uncomfortable and inconsistent talking to patients about specific marijuana health effects. Additional education is warranted, particularly as it relates to talking to patients about the danger of second hand smoke exposure, underage use, safe storage, and the over-consumption of edibles.

Medical cannabis access, use, and substitution for prescription opioids and other substances: A survey of authorized medical cannabis patients.

BACKGROUND: In 2014 Health Canada replaced the Marihuana for Medical Access Regulations (MMAR) with the Marihuana for Medical Purposes Regulations (MMPR). One of the primary changes in the new program has been to move from a single Licensed Producer (LP) of cannabis to multiple Licensed Producers. This is the first comprehensive survey of patients enrolled in the MMPR. METHODS: Patients registered to purchase cannabis from Tilray, a federally authorized Licenced Producer (LP) within the MMPR, were invited to complete an online survey consisting of 107 questions on demographics, patterns of use, and cannabis substitution effect. The survey was completed by 271 respondents. RESULTS: Cannabis is perceived to be an effective treatment for diverse conditions, with pain and mental health the most prominent. Findings include high self-reported use of cannabis as a substitute for prescription drugs (63%), particularly pharmaceutical opioids (30%), benzodiazepines (16%), and antidepressants (12%). Patients also reported substituting cannabis for alcohol (25%), cigarettes/tobacco (12%), and illicit drugs (3%). A significant percentage of patients (42%) reported accessing cannabis from illegal/unregulated sources in addition to access via LPs, and over half (55%) were charged to receive a medical recommendation to use cannabis, with nearly 25% paying $300 or more. CONCLUSION: The finding that patients report its use as a substitute for prescription drugs supports prior research on medical cannabis users; however, this study is the first to specify the classes of prescription drugs for which cannabis it is used as a substitute, and to match this substitution to specific diagnostic categories. The findings that some authorized patients purchase cannabis from unregulated sources and that a significant percentage of patients were charged for medical cannabis recommendations highlight ongoing policy challenges for this federal program.

Butane Hash Oil Burns: A 7-Year Perspective on a Growing Problem.

With the legalization of marijuana in four states, and decriminalization in many others, marijuana is becoming easier to obtain. The authors have experienced an increase in burn injuries related to the production of butane hash oil (BHO; a concentrated tetrahydrocannabinol product produced by the distillation of marijuana plant products with pressurized butane). This article updates our experience and highlights the increasing public health problem associated with these burns. Charts of patients who presented to the burn center with suspicion of BHO-related injuries between January 2007 and December 2014 were examined. Data collected included demographics, injury characteristics, treatment utilized, and outcomes. Charts of 101 patients were identified as having BHO-related burn injury. The mean age of these patients was 30.5 ± 10.6 years (mean ± standard deviation, range: 2-55 years) and 93.1% were male. Patients sustained a mean of 26.8 ± 24.1% TBSA burn with 14.3 ± 25.1% third degree burns. Three patients died as the result of their injuries. Patients required a mean of 12 ± 48.4 ventilator days, and 27.1 ± 59.4 days in the hospital. The number of patients presenting with these burns increased over the past 7 years. BHO burns occur most commonly in February (12 patients), on Wednesday (19 patients), and between 18:00 and 06:00 (58 patients). There has been a sharp increase in the number of patients presenting with burn-associated BHO production in the region over the past 7 years. The authors as burn care providers need to increase public awareness of this issue and aid in the development of legislation to help prevent these burns before it becomes a public health crisis.

State-level medical marijuana laws, marijuana use and perceived availability of marijuana among the general U.S. population.

BACKGROUND: Little is known on how perceived availability of marijuana is associated with medical marijuana laws. We examined the relationship between medical marijuana laws (MML) and the prevalence of past-month marijuana use, with perceived availability of marijuana. METHODS: Data were from respondents included in the National Survey of Drug Use and Health restricted use data portal 2004-2013. Multilevel logistic regression of individual-level data was used to test differences between MML and non-MML states and changes in prevalence of past-month marijuana use and perceived availability from before to after passage of MML among adolescents, young adults and older adults controlling for demographics. RESULTS: Among adults 26+, past-month prevalence of marijuana use increased from 5.87% to 7.15% after MML passage (Adjusted Odds Ratio (AOR): 1.24 [1.16-1.31]), but no change in prevalence of use was found for 12-17 or 18-25 year-olds. Perceived availability of marijuana increased after MML was enacted among those 26+ but not in younger groups. Among all age groups, prevalence of marijuana use and perception of it being easily available was higher in states that would eventually pass MML by 2013 compared to those that had not. Perceived availability was significantly associated with increased risk of past-month marijuana use in all age groups. CONCLUSION: Evidence suggests perceived availability as a driver of change in use of marijuana due to MML. To date, this has only occurred in adults 26+ and different scenarios that could explain this change need to be further explored.