Public Health Impact of Cannabis Legalization: What Do We Know so Far?

Presented at the 2019 Medical Cannabis Symposium: The intersection of clinical practice and science

Rutgers University and New Jersey Department of HealthDecember 2019

Beatriz H Carlini, PhD, MPH

It is a brave new world

It is a brave new world

Agenda for today

Cannabis Legalization

Product

Market

People

Other products

State Cannabis Programs

2016

2016

2016

2018

2018

2016

^

* VT and DC have legal medical marketplaces, but no legal adult use marketplaces^ The KS Governor passed a bill to exempt CBD oil from the definition of marijuana, effectively legalizing CBD, though no THC is allowed in the product

Source: Schauer, G. Overview of Cannabis Policies in U.S. States: Implications for Public Health. Presented at North American Cannabis Summit, Los Angeles, Jan 2019

*

*

Medicinal laws

• Compassion

• Patient-centered

• Qualifying conditions and regulations vary widely

New Jersey• Chronic pain musculoskeletal disorders (28.9%),

• Anxiety (23.8%)

• Intractable skeletal spasticity (15.3%)

• PTSD (7.9%)

• Pain due to cancer or HIV (5.6%)

• Recent inclusion of Opiate Use Disorders

Source: https://www.nj.gov/health/news/2019/approved/20190724b.shtml accessed 12.15.19

Non medical legalization

Prohibition = Mass incarceration

= Unsafe and potent product

Legalization = Criminal justice

= Safe, regulated products

= Revenues for public good

= Substitution

Time, manner and regulations vary: home grow, cap on retail stores and personal use, taxation, warning labels, advertising.

Fifty shades of weed

Cannabis Legalization

Product

Market

People

Other products

Marijuana flowers potency, WA.

Smart R, Caulkins JP, Kilmer B, Davenport S, Midgette G. Variation in cannabis potency and prices in a newly legal market:

evidence from 30 million cannabis sales in Washington state. Addiction. 2017 May 27. doi: 10.1111/add.13886. [Epub ahead of print]

20% THC

Industry perspective• 69% THC• Shelf stable• Imperfect buds

Consumer perspective• 69% THC• “Healthier”• No scent

Product diversification

Concentrates: diversification of production

Carlini B. Vaping Marijuana. Alcohol & Drug Abuse Institute, University of Washington, June 2016. URL: http://LearnAboutMarijuanaWA.org/factsheets/vaping.htm.

Water

• Kief

• Hash

Solvent

• Wax

• Shatter

• BHO

• RSO

CO2

• CO2 Oil

Naphtha, Ether, Butane Glycerol

Concentrates’ market share in WA.

22%

66%

+ 146%

- 22%

Smart R, Caulkins JP, Kilmer B, Davenport S, Midgette G. Variation in cannabis potency and prices in a newly legal market:

evidence from 30 million cannabis sales in Washington state. Addiction. 2017 May 27. doi: 10.1111/add.13886. [Epub ahead of print]

Product Innovation – delivery devices

Dabbing: traditional paraphernalia

https://www.leafly.com/news/cannabis-101/how-to-dab-cannabis-concentrates Retrieved 10.27.2016

1- MJ concentrate2- Water pipe3- Nail4- Dome5- Torch6- Dabber

E-Dabs

https://www.leafly.com/news/strains-products/the-best-dab-rig-for-any-situation. Retrieved 10.27.2016

Quality control and Testing

Contaminants/residues

• Pesticides

• Heavy Metals

• Mold and mildew

Pesticide residues in Washington State

present in 84.6% of 24 market samples,

including potentially neurotoxic and

carcinogenic agents

Quality control and Testing

✓ No universal standards for laboratory testing protocols

✓ Systematic differences in the cannabinoid content reported by different laboratories

THC content

https://www.leafly.com/news/industry/leafly-investigation-washingtons-top-cannabis-lab-inflating-thc-numbers, retrieved 7.23.19

Accreditation Program: 2024

Summary- products

Non-medical legalization:

- Has not decreased potency

- Has not assured a safer product

- And there is the vaping crisis!

Things may change!

- The industry is not mature, is not sanctioned at a federal level and is market-oriented

- Regulatory agencies don’t have federal guidance neither track record

Price and advertising

Cannabis Legalization

Product

Market

People

Other products

Nascent market: price, volume, demand

Advertising:mainstreaming

Normalization: Everybody is doing it!

Marijuana advertisement exposure is high

High school students nationwide (n=12,988)

Recent months:

• 52.8% internet

• 32.1 % TV

• 24.1% magazine and newspapers

• 19.7% from radio

• 19% storefronts

• 16.6% from billboards

Dai H. Exposure to Advertisements and Marijuana Use Among US Adolescents. Prev Chronic Dis 2017;14:170253. DOI: http://dx.doi.org/10.5888/pcd14.170253

Summary: Nascent Market

• Production is not based on demand

• Advertising – create a demand

• New consumers

• Intensify use among current consumers

Cannabis use and associated problems

Cannabis Legalization

Product

Market

People

Other products

Where do we find data?

Most recent and comprehensive

• Data source: NSDUH-

• Representatives of states: WA, CO, AK and OR

• 2008-2016

• 17,000 to 18,000 per age group

Dr. Silvia Martins et al – School of Public Health at Columbia University

Medical and Recreational Marijuana Laws in Adolescents and Young Adults: Where Do We Go from Here?. 3rd Annual Scientific Meeting

of the Research Society on Marijuana (RSMj), July 26-28, 2019, Vancouver, WA.

https://researchmj.org/resources/RSMj%20Full%20Conference%20Program%202019.pdf

Past month marijuana use before and after legalization, by age

4.8

13.1

5.75.3

14

7.1

0

2

4

6

8

10

12

14

16

Age 12-17 Age 18-25 Age 26+

% o

f Pa

st M

on

th U

se

Before After

OR=1.28 (1.16,1.40)

Dr. Silvia Martins et al – School of Public Health at Columbia University

Medical and Recreational Marijuana Laws in Adolescents and Young Adults: Where Do We Go from Here?. 3rd Annual Scientific Meeting of the Research Society

on Marijuana (RSMj), July 26-28, 2019, Vancouver, WA.

Daily marijuana use before and after legalization among among last month users

22.9

38.337.1

23.2

40.5

37.8

0

5

10

15

20

25

30

35

40

45

Age 12-17 Age 18-25 Age 26+

% w

ho

use

mar

ijuan

a d

aily

Before After

Dr. Silvia Martins et al – School of Public Health at Columbia University

Medical and Recreational Marijuana Laws in Adolescents and Young Adults: Where Do We Go from Here?. 3rd Annual Scientific Meeting of the

Research Society on Marijuana (RSMj), July 26-28, 2019, Vancouver, WA.

Past year Cannabis Use Disorder among past year users

22.8

16.6

9.1

27.2

15.7

10.4

0

5

10

15

20

25

30

Age 12-17 Age 18-25 Aged 26+

% C

UD

am

on

g p

ast

year

use

rs

Before After

Dr. Silvia Martins et al – School of Public Health at Columbia University

Medical and Recreational Marijuana Laws in Adolescents and Young Adults: Where Do We Go from Here?. 3rd Annual Scientific Meeting of the Research

Society on Marijuana (RSMj), July 26-28, 2019, Vancouver, WA.

OR= 1.27 (1.01,1.59) –analysis indicates confounder

Source: WA Poison Center 2018 Annual Data Report – Cannabishttps://www.wapc.org/data/data-reports/cannabis-data-report/

Increase is consistent with national trends

Panic, anxiety and Cannabis Hyperemesis Syndrome

Summary: people

• Adults (26+) are increasing cannabis use

• No evidence of increase among youth

• Modest increase in problems

• Things may change - too early

• We need better measures, more research

Tobacco, Alcohol and Opiates

Cannabis Legalization

Product

Market

People

Other products

Addition or substitution?

Can cannabis substitute for opioids?

Yes: Preliminary research

▪ Patients narratives▪ One longitudinal study(*)

•Among people willing to utilize cannabis• Self Report•Observational

• Sexton M et al. A Cross-Sectional Survey of Medical Cannabis Users: Patterns of Use and Perceived Efficacy. Cannabis and Cannabinoid Research.

2016;1(1):131-8

• Ilgen MA et al. Characteristics of adults seeking medical marijuana certification. Drug Alcohol Depend. 2013;132(3):654-9.

• Bruce D et al. Preferences for Medical Marijuana over Prescription Medications Among Persons Living with Chronic Conditions:

Alternative, Complementary, and Tapering Uses. Journal of alternative and complementary medicine. 2018 Feb;24(2):146-153.

• Corroon JM, Jr., Mischley LK, Sexton M. Cannabis as a substitute for prescription drugs - a cross-sectional study. Journal of pain research.

2017;10:989-98.

• Reiman A et al. Cannabis as a Substitute for Opioid-Based Pain Medication: Patient Self-Report. Cannabis and cannabinoid research. 2017;2(1):160-

6.

• Boehnke KF et al. Medical Cannabis Use Is Associated With Decreased Opiate Medication Use in a Retrospective Cross-Sectional Survey of Patients

With Chronic Pain. The journal of pain : official journal of the American Pain Society. 2016;17(6):739-44.

• Lucas P et al. Substituting cannabis for prescription drugs, alcohol and other substances among medical cannabis patients:

The impact of contextual factors. Drug Alcohol Rev. 2016;35(3):326-33.

• Lucas P, Walsh Z. Medical cannabis access, use, and substitution for prescription opioids and other substances: A survey of authorized medical

cannabis patients. The International journal on Drug Policy. 2017;42:30-5.

• Nugent SM et al. Patterns and correlates of medical cannabis use for pain among patients prescribed long-term opioid therapy.

Gen Hosp Psychiatry. 2018;50(Supplement C):104-10.

• (*) Vigil JM et al. Associations between medical cannabis and prescription opioid use in chronic pain patients: A preliminary cohort study. PLoS

One. 2017;12(11):e0187795.

Barriers to substitution

▪ Access to cannabis as a medication:

▪ FDA regulated: stable product, studied in RCTs

▪ Covered by insurance

▪ Recommended by an educated health care force

▪ Cannabis as a harm reduction alternative

▪ No date, combination instead of substitution among high risk populations

▪ US – market-oriented legalization

Summary – Cannabis and other drugs

• Substitution makes sense in theory

• Profit and markets are driving legalization

• Federal prohibition hinders research on substitution

• Health services policies hinders ability to substitute

Final considerations

• Cannabis legalization – promises, promises

• Legalization is in its infancy

• Many moving pieces

• Our voices matter

• We can shape the next decade

Thanks!

Bia@uw.edu

Beatriz H. Carlini, PhD, MPH

Senior Research Scientist

Alcohol and Drug Abuse Institute- ADAI

Affiliate Associate Professor and

Director, Tobacco Studies Program

School of Public Health, Health Services

University of Washington