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As cannabinoid-based medications gain popularity in the treatment of refractory medical conditions, it is crucial to examine the neurocognitive effects of commonly prescribed products to ensure associated safety profiles. The present study aims to investigate the acute effects of a standard 1 mL sublingual dose of CannEpil®, a medicinal cannabis oil containing 100 mg cannabidiol (CBD) and 5 mg Δ9-tetrahydrocannabinol (THC) on neurocognition, attention, and mood. A randomised, double-blind, placebo-controlled, within-subjects design assessed 31 healthy participants (16 female, 15 male), aged between 21 and 58 years, over a two-week experimental protocol. Neurocognitive performance outcomes were assessed using the Cambridge Neuropsychological Test Automated Battery, with the Profile of Mood States questionnaire, and the Bond-Lader Visual Analogue Scale used to assess subjective state and mood. CannEpil increased Total Errors in Spatial Span and Correct Latency (median) in Pattern Recognition Memory, while also increasing Efficiency Score (lower score indicates greater efficiency) relative to placebo (all p < .05). Subjective Contentedness (p < .01) and Amicability (p < .05) were also increased at around 2.5 h post dosing, relative to placebo. Drowsiness or sedative effect was reported by 23 % of participants between three to six hours post CannEpil administration. Plasma concentrations of CBD, THC, and their metabolites were not significantly correlated with any observed alterations in neurocognition, subjective state, or adverse event occurrence. An acute dose of CannEpil impairs select aspects of visuospatial working memory and delayed pattern recognition, while largely preserving mood states among healthy individuals. Intermittent reports of drowsiness and sedation underscore the inter-individual variability of medicinal cannabis effects on subjective state. (ANZCTR; ACTRN12619000932167; https://www.anzctr.org.au)., Competing Interests: Declaration of competing interest AH is supported by a Rebecca L Cooper Al and Val Rosenstrauss Fellowship (GNT: F2021894). BM, SC, CS, BS, and LD have no conflicts of interest to declare., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Fibromyalgia is a complex disease process that is as prevalent as it is poorly understood. Research into the pathophysiology is ongoing, and findings will likely assist in identifying new therapeutic options to augment those in existence today that are still insufficient for the care of a large population of patients. Recent evidence describes the use of cannabinoids in the treatment of fibromyalgia. This study provides a systematic, thorough review of the evidence alongside a review of the seminal data regarding the pathophysiology, diagnosis, and current treatment options. Fibromyalgia is characterized by widespread chronic pain, fatigue, and depressive episodes without an organic diagnosis, which may be prevalent in up to 10% of the population and carries a significant cost in healthcare utilization, morbidity, a reduced quality of life, and productivity. It is frequently associated with psychiatric comorbidities. The diagnosis is clinical and usually prolonged, and diagnostic criteria continue to evolve. Some therapies have been previously described, including neuropathic medications, milnacipran, and antidepressants. Despite some level of efficacy, only physical exercise has strong evidence to support it. Cannabis has been used historically to treat different pain conditions since ancient times. Recent advances allowed for the isolation of the active substances in cannabis and the production of cannabinoid products that are nearly devoid of psychoactive influence and provide pain relief and alleviation of other symptoms. Many of these, as well as cannabis itself, are approved for use in chronic pain conditions. Evidence supporting cannabis in chronic pain conditions is plentiful; however, in fibromyalgia, they are mostly limited. Only a handful of randomized trials exists, and their objectivity has been questioned. However, many retrospective trials and patient surveys suggest the significant alleviation of pain, improvement in sleep, and abatement of associated symptoms. Evidence supporting the use of cannabis in chronic pain and specifically in fibromyalgia is being gathered as the use of cannabis increases with current global trends. While the current evidence is still limited, emerging data do suggest a positive effect of cannabis in fibromyalgia. Cannabis use is not without risks, including psychiatric, cognitive, and developmental as well as the risks of addiction. As such, clinical judgment is warranted to weigh these risks and prescribe to patients who are more likely to benefit from this treatment. Further research is required to define appropriate patient selection and treatment regimens., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to disclose., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Posttraumatic stress disorder (PTSD) is an often chronic condition for which currently available medications have limited efficacy. Medical cannabis is increasingly used to treat patients with PTSD; however, evidence for the efficacy and safety of cannabinoids is scarce. To learn more about patients' opinions on and experiences with medical cannabis, we organized a focus group discussion among military veterans (N = 7) with chronic PTSD who were treated with medical cannabis. Afterwards, some of their partners (N = 4) joined the group for an evaluation, during which they shared their perspective on their partner's use of medical cannabis. Both sessions were audio-recorded, transcribed verbatim, and analyzed by means of qualitative content analysis. Five overarching themes were identified. The first four themes related to the different phases of medical cannabis use - namely, 1) Consideration; 2) Initiation; 3) Usage; and 4) Discontinuation. The fifth theme related to several general aspects of medical cannabis use. Patients used medical cannabis to manage their symptoms and did not experience an urge to "get high." They used a variety of different cannabis strains and dosages and reported several therapeutic effects, including an increased quality of sleep. Furthermore, discussions about the experienced stigma surrounding cannabis generated insights with implications for the initiation of medical cannabis use. These results underscore the value of qualitative research in this field and are relevant for the design of future clinical trials on the use of medical cannabis for the treatment of PTSD., Competing Interests: Declaration of Competing Interest All authors declare that they have no conflicts of interest., (Copyright © 2020. Published by Elsevier B.V.)

Objectives: To evaluate safety and pharmacokinetic parameters (PK) of medical cannabis in add-on for children and young adults with drug-resistant epilepsy., Design, Setting: Ten patients (4 females, 6 males, age 2.5-23.2 years) were enrolled in a prospective open trial with a galenic preparation (decoction) of Italian cannabis (FM2, ratio THC:CBD = 3:5, range THC 5.2-7.2 %; CBD 8.2-11.1 %). Patients received the first dose in Hospital, progressively augmented by CBD dose titration (from 1 to 4 mg/kg/day)., Outcome Measures: In order to assess safety, blood parameters, heart rates and electrocardiograms (ECGs) were evaluated before the enrollment and during the follow up. The PK study was performed measuring THC and CBD concentrations by UHPLC-MS/MS in plasma samples collected during the first administration and at each follow-up visit., Results: Two out of ten patients stopped the treatment for adverse events (detected in 6/10: gastroenteric, sleep or behavioral disorders) and difficulties in drug supply. We observed minor ECG alterations in two patients and asymptomatic transient reductions of fibrinogen after 6 months of therapy. The PK study during follow-up revealed statistically significant correlations between THC-CBD blood concentrations and: volumes of decoction, FM2 and THC-CBD daily dosages., Conclusions: The present study, although with some limitations, shows a good safety profile of medical cannabis in children and young patients with drug-resistant epilepsy and encourages the possibility of further studies with oral cannabis-based drugs. The correlations between THC-CBD plasma concentrations and their administered dosages underline the need of a therapeutic drug monitoring for cannabinoids therapy., Competing Interests: Declaration of Competing Interest All the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Monitoring pharmacological active compounds in pharmaceutical preparations of medical cannabis and in conventional and non-conventional biological matrices of treated individuals use requires both a wide linear range and sensitive detection. We have developed and validated a fast and sensitive method using ultra-high performance liquid chromatography coupled with tandem mass spectrometry (UHPLC-MS/MS) for analysis of Δ-9-tetrahydrocannabinol (THC), cannabidiol (CBD), their acidic precursors Δ-9-tetrahydrocannabinolic acid A (THCA-A) and cannabidiolic acid (CBDA) and some major metabolites of THC such as 11-nor-9-carboxy-THC (THC-COOH), 11-hydroxy-THC (11-OH-THC), Δ-9-THC-Glucuronide (THC-GLUC) and THC-COOH-Glucuronide (THC-COOH-GLUC) in conventional (whole blood and urine) and non-conventional (oral fluid and sweat) of individual treated with medical cannabis preparation. Specifically, THC, THCA-A, CBD and CBD-A were determined in cannabis decoction and oil prepared to treat individuals. The method used positive electrospray ionization (ESI) mode to reach the sensitivity needed to detect minimal amounts of analytes under investigations exposure with limits of quantification ranging from 0.2 to 0.5 ng per milliliter (ng/mL) or ng per patch in case of collected sweat. The validation results indicated this method was accurate (average inter/intra-day error, <10%), precise (inter/intra-day imprecision, <10%), and fast (10 min run time). In addition, time-consuming sample preparation was avoided applying dilute and shoot procedure, meeting the needs for potential large-scale population studies. The analysis of real samples demonstrated a pharmacokinetics of cannabinoids, their precursors and their metabolites dependent from quantity of carboxylated and decarboxylated compounds in pharmaceutical preparations., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Many Americans rely on opioids at varying dosages to help ameliorate their suffering. However, empirical evidence is mounting that opioids are ineffective at controlling non-cancer related chronic pain, and many argue the strategies meant to relieve patient suffering are contributing to the growing opioid epidemic. Concurrently, several states now allow the use of medical cannabis to treat a variety of medical conditions, including chronic pain. Needing more exploration is the impact of cannabis laws on general opioid reliance and whether chronic pain sufferers are opting to use cannabis medicinally instead of opioids., Methods: This study investigates the effect of Medical Marijuana Laws (MML)s on opioid use and misuse controlling for a number of relevant factors using data from several years of the National Survey on Drug Use and Health and multivariate logistic regression and longitudinal analysis strategies., Results: Results provide evidence that MMLs may be effective at reducing opioid reliance as survey respondents living in states with medical cannabis legislation are much less apt to report using opioid analgesics than people living in states without such laws, net other factors. Results further indicate that the presence of medicinal cannabis legislation appears to have no influence over opioid misuse., Conclusion: MMLs may ultimately serve to attenuate the consequences of opioid overreliance., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Prompted by the ongoing debate regarding whether cannabis serves as a complement to or substitute for alcohol, this study uses prospective data to examine daily associations between medicinal versus recreational cannabis and alcohol use in veterans., Methods: Three semi-annual waves of Timeline Followback Interview data were collected from a sample of veterans who reported co-using alcohol and cannabis on at least one day (N = 115; 56% medicinal users; 93% male; 62,100 observations). Linear mixed effects models were used to examine the association between daily cannabis use and number of drinks consumed across time for both medicinal and recreational users and to examine the frequency medicinal cannabis used to substitute for alcohol., Results: Compared to medicinal users, recreational users were more likely to drink more on cannabis use days relative to non-use days. Among medicinal users, those endorsing more frequent use of cannabis as a substitute for alcohol reported fewer number of drinks consumed on days when cannabis was used relative to non-use days., Conclusions: Among veterans, recreational users are at greater risk for increased drinking when co-using cannabis at the daily level, an association that is stable over time. Medicinal users may be at lower risk for increased drinking on days when cannabis is also used, especially those who endorse using cannabis to substitute for alcohol. Findings help clarify the debate on cannabis-alcohol substitution or complementary associations in a sample of veterans and suggests that alcohol interventions should address cannabis use as a risk factor, especially for recreational users., (Copyright © 2019 Elsevier B.V. All rights reserved.)

The United States has witnessed enormous changes concerning the acceptance of medicinal and recreational cannabis use. Sixty-three percent of the US population has access to medicinal cannabis markets, which offer increasingly diverse and potent cannabis products. Considering the rapidly changing cultural, political, and legal landscape, the scientific literature does not adequately inform public policy, medical decision making, or harm reduction approaches. The goals of this paper are to (1) investigate the state of cannabis research on medical conditions commonly treated with cannabis, (2) review the barriers that have led to large gaps between cannabis use and available empirical data, and (3) suggest a path forward with new research designs to address these gaps. Thus, we aim to advance a more nuanced understanding of the barriers to cannabis research and suggest innovative research designs necessary for rapid development of a meaningful knowledge base., (Copyright © 2019 ISPOR–The Professional Society for Health Economics and Outcomes Research. Published by Elsevier Inc. All rights reserved.)

Purpose: Interest in the use of artisanal cannabinoids in pediatric epilepsy has increased but safety and utility data are lacking. Our aim was to prospectively characterize the use of oral cannabis extracts (OCE) in a refractory pediatric epilepsy population., Methods: Families considering the use of an OCE were enrolled in a prospective observational study. Baseline seizure frequency was assessed over a period of 4 weeks. Seizure frequency, CBD and THC-COOH levels were assessed every 4 weeks during a 12-week treatment period. Response was defined as at least a 50% reduction in seizure frequency over the final 8 weeks of the study relative to baseline., Results: Consent was obtained in 32 children; 11 were excluded from analysis (3 failed to complete baseline data, 3 started OCE before completing baseline period and 5 did not start OCE) leaving 21 to be included in subsequent analyses. Median age was 10.3 years (IQR 6.8-12.6), 13 (62%) were male and median seizure frequency was 2.7 seizures/day during the baseline period. The median of the high dose of CBD that was administered during the observation period was of 0.9 (0.6-2.2) mg/kg/day. Of the 21 subjects who were included in the analysis, 5 (24%) were responders. OCE was stopped early in 3 subjects (14%) due to a perceived increase in seizures. THC-COOH and CBD blood levels did not have a significant association with response status (p = 0.95 CBD, p = 0.53 THC-COOH, N = 14)., Conclusion: The observed response rate in this study is similar to placebo rates in prospective randomized trials of pharmaceutical grade products and the withdrawal rate is greater than rates obtained with retrospective methods. Doses of OCE administered were lower than doses used in randomized trials., (Copyright © 2019 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.)

We assess the current and describe possible future public health impacts of the legalisation of cannabis production, sale, and use in the Americas. First, we describe global patterns of cannabis use and their most probable adverse health effects. Second, we summarise evidence regarding the effectiveness of cannabinoids for medicinal use and describe approaches that have been used to regulate the use of medicinal cannabis and how these approaches might have affected medicinal and recreational use and harms (eg, road crashes). Third, we describe how jurisdictions that have legalised recreational use have regulated production and sale of cannabis. Fourth, we evaluate the effects of cannabis legalisation on cannabis use and harms and on the use of alcohol, tobacco, and other drugs. Fifth, we use alcohol and tobacco policy examples to identify possible long-term public health effects of cannabis legalisation. Finally, we outline policy approaches that could minimise harms to public health arising from the legalisation of a commercial cannabis industry., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Driving under the influence of cannabis (DUIC) is a public health concern among those using medical cannabis. Understanding behaviors contributing to DUIC can inform prevention efforts. We evaluated three past 6-month DUIC behaviors among medical cannabis users with chronic pain., Methods: Adults (N = 790) seeking medical cannabis certification or recertification for moderate/severe pain were recruited from February 2014 through June 2015 at Michigan medical cannabis clinics. About half of participants were male (52%) and 81% were White; their Mean age was 45.8 years. Participants completed survey measures of DUIC (driving within 2 h of use, driving while "a little high," and driving while "very high") and background factors (demographics, alcohol use, etc.). Unadjusted and adjusted logistic regressions were used to examine correlates of DUIC., Results: For the past 6 months, DUIC within 2 h of use was reported by 56.4% of the sample, DUIC while a "little high" was reported by 50.5%, and "very high" was reported by 21.1%. Greater cannabis quantity consumed and binge drinking were generally associated with DUIC behaviors. Higher pain was associated with lower likelihood of DUIC. Findings vary somewhat across DUIC measures., Conclusions: The prevalence of DUIC is concerning, with more research needed on how to best measure DUIC. Prevention messaging for DUIC may be enhanced by addressing alcohol co-consumption., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objectives: Medical marijuana use may substitute prescription opioid use, whereas nonmedical marijuana use may be a risk factor of prescription opioid misuse. This study examined the associations between recreational marijuana legalization and prescription opioids received by Medicaid enrollees., Methods: State-level quarterly prescription drug utilization records for Medicaid enrollees during 2010-2017 were obtained from Medicaid State Drug Utilization Data. The primary outcome, opioid prescriptions received, was measured in three population-adjusted variables: number of opioid prescriptions, total doses of opioid prescriptions in morphine milligram equivalents, and related Medicaid spending, per quarter per 100 enrollees. Two difference-in-difference models were used to test the associations: eight states and DC that legalized recreational marijuana during the study period were first compared among themselves, then compared to six states with medical marijuana legalized before the study period. Schedule II and III opioids were analyzed separately., Results: In models comparing eight states and DC, legalization was not associated with Schedule II opioid outcomes; having recreational marijuana legalization effective in 2015 was associated with reductions in number of prescriptions, total doses, and spending of Schedule III opioids by 32% (95% CI: (-49%, -15%), p = 0.003), 30% ((-55%, -4.4%), p = 0.027), and 31% ((-59%, -3.6%), p = 0.031), respectively. In models comparing eight states and DC to six states with medical marijuana legalization, recreational marijuana legalization was not associated with any opioid outcome., Conclusions: No evidence suggested that recreational marijuana legalization increased prescription opioids received by Medicaid enrollees. There was some evidence in some states for reduced Schedule III opioids following the legalization., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Aims: The aim of this research was to determine the association between legalizing medical marijuana and workplace fatalities., Design: Repeated cross-sectional data on workplace fatalities at the state-year level were analyzed using a multivariate Poisson regression., Setting: To date, 29 states and the District of Columbia have legalized the use of marijuana for medicinal purposes. Although there is increasing concern that legalizing medical marijuana will make workplaces more dangerous, little is known about the relationship between medical marijuana laws (MMLs) and workplace fatalities., Participants: All 50 states and the District of Columbia for the period 1992-2015., Measurements: Workplace fatalities by state and year were obtained from the Bureau of Labor Statistics. Regression models were adjusted for state demographics, the unemployment rate, state fixed effects, and year fixed effects., Findings: Legalizing medical marijuana was associated with a 19.5% reduction in the expected number of workplace fatalities among workers aged 25-44 (incident rate ratio [IRR], 0.805; 95% CI, .662-.979). The association between legalizing medical marijuana and workplace fatalities among workers aged 16-24, although negative, was not statistically significant at conventional levels. The association between legalizing medical marijuana and workplace fatalities among workers aged 25-44 grew stronger over time. Five years after coming into effect, MMLs were associated with a 33.7% reduction in the expected number of workplace fatalities (IRR, 0.663; 95% CI, .482-.912). MMLs that listed pain as a qualifying condition or allowed collective cultivation were associated with larger reductions in fatalities among workers aged 25-44 than those that did not., Conclusions: The results provide evidence that legalizing medical marijuana improved workplace safety for workers aged 25-44. Further investigation is required to determine whether this result is attributable to reductions in the consumption of alcohol and other substances that impair cognitive function, memory, and motor skills., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: Previous research shows that between individuals there is a positive association between medically motivated use and cannabis use frequency and quantity. While between-subjects' analyses are useful for understanding shared vulnerabilities, research has so far not examined within-subjects' relationships which are closer to evaluating functional relationships (i.e., do individuals tend to use cannabis more heavily subsequent to elevations in pain experiences?). To better understand the association between experiences of pain and cannabis use, the current paper examines whether there is a functional within-subjects association between experiences of pain and heavy cannabis use., Methods: 182 regular cannabis users without a medical cannabis license were asked to report momentary experiences of physical pain, whether they had used cannabis, and if so, quantity consumed five times per day over a five-day period on their smartphones. Mixed effects models examined the relations between within- and between-subjects experiences of pain and cannabis use and quantity consumed., Results: Elevated experiences of pain were not associated with cannabis use occasions at the within- or between-subjects level. Experiences of pain were associated with greater amount of cannabis consumed at the within-subjects level, but not at the between-subjects level., Conclusions: Experiences of pain are not associated with decisions about whether or not to use cannabis. Once cannabis users are in cannabis-using situations, they tend to use larger amounts when they are experiencing elevated levels of pain. This may have implications for cannabis abuse treatment as pain may make it more difficult for users to reduce their consumption., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: Marijuana use during adolescence is associated with neurocognitive deficits and poorer functioning across several domains. It is likely that more states will pass both medical and recreational marijuana legalization laws in the coming elections; therefore, we must begin to look more closely at the longitudinal effects of medical marijuana (MM) advertising on marijuana use among adolescents so that we can better understand effects that this advertising may have on their subsequent marijuana use and related outcomes., Methods: We followed two cohorts of 7th and 8th graders (mean age 13) recruited from school districts in Southern California from 2010 until 2017 (mean age 19) to examine effects of MM advertising on adolescents' marijuana use, cognitions, and consequences over seven years. Latent growth models examined trajectories of self-reported exposure to medical marijuana ads in the past three months and trajectories of use, cognitions, and consequences., Results: Higher average exposure to MM advertising was associated with higher average use, intentions to use, positive expectancies, and negative consequences. Similarly, higher rates of change in MM advertising exposure were associated with higher rates of change in use, intentions, expectancies, and consequences over seven years., Conclusions: Results suggest that exposure to MM advertising may not only play a significant role in shaping attitudes about marijuana, but may also contribute to increased marijuana use and related negative consequences throughout adolescence. This highlights the importance of considering regulations for marijuana advertising, similar to regulations in place for the promotion of tobacco and alcohol in the U.S., (Copyright © 2018. Published by Elsevier B.V.)

Aims: The purpose of this paper is to analyze characteristics of marijuana concentrate users, describe patterns and reasons of use, and identify factors associated with daily use of concentrates among U.S.-based cannabis users recruited via a Twitter-based online survey., Methods: An anonymous Web-based survey was conducted in June 2017 with 687 U.S.-based cannabis users recruited via Twitter-based ads. The survey included questions about state of residence, socio-demographic characteristics, and cannabis use including marijuana concentrates. Multiple logistic regression analyses were conducted to identify characteristics associated with lifetime and daily use of marijuana concentrates., Results: Almost 60% of respondents were male, 86% were white, and the mean age was 43.0 years. About 48% reported marijuana concentrate use. After adjusting for multiple testing, significant predictors of concentrate use included: living in "recreational" (AOR = 2.04; adj. p = .042) or "medical, less restrictive" (AOR = 1.74; adj. p = .030) states, being younger (AOR = 0.97, adj. p = .008), and daily herbal cannabis use (AOR = 2.57, adj. p = .008). Out of 329 marijuana concentrate users, about 13% (n = 44) reported daily/near daily use. Significant predictors of daily concentrate use included: living in recreational states (AOR = 3.59, adj. p = .020) and using concentrates for therapeutic purposes (AOR = 4.34, adj. p = .020)., Conclusions: Living in states with more liberal marijuana policies is associated with greater likelihood of marijuana concentrate use and with more frequent use. Characteristics of daily users, in particular, patterns of therapeutic use warrant further research with community-recruited samples., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: Self-medication with drugs or alcohol is commonly reported among adults with mood or anxiety disorders, and increases the risk of developing substance use disorders. Medical marijuana laws (MML) may be associated with greater acceptance of the therapeutic value of marijuana, leading individuals to self-medicate., Methods: The study utilized data from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (2004-2005). Participants were sampled from households in the general population and included adults with a mood or anxiety disorder in the past 12 months (n = 7418), and the subset of those who used marijuana and no other drug (n = 314). Weighted logistic regression models predicted the prevalence of self-medication with drugs in U.S. states with and without MML, adjusting for individual and state-level covariates. As a negative control, analyses were repeated for self-medication with alcohol., Results: Overall, self-medication with drugs was 3.73 percentage points higher (95% confidence interval [CI]: 0.93-6.53) among those living in MML states (p = 0.01). For the subpopulation that only used marijuana, self-medication with drugs was 21.22 percentage points higher (95% CI: 3.91-38.53) among those living in MML states (p = 0.02). In contrast, self-medication with alcohol had nearly identical prevalence in MML and non-MML states, overall and for drinkers., Conclusions: Among adults with mood or anxiety disorders, living in a medical marijuana law state is associated with self-medication with marijuana. While additional research is needed to determine the reasons for this association, clinical screening for self-medication with marijuana may be particularly important in states with medical marijuana laws., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: Since marijuana became legal for medical use in California in 1996, reasons for medical use among medical marijuana patients (MMP) have become increasingly well described in qualitative studies. However, few studies have detailed how the use of marijuana for medical purposes fits into the broader career trajectories of either becoming a marijuana user or becoming a MMP, including the social influences on medical use., Methods: Young adult MMP (N=40) aged 18 to 26 years old were recruited in Los Angeles, CA in 2014-15 and administered a semi-structured interview that included questions focusing on marijuana use practices before and after becoming MMP., Results: MMP were categorized into three trajectory groups: primarily medical users (n=30); primarily non-medical users (n=3); and medical users who transitioned to non-medical users (n=7). Most medical users discovered medicinal effects from marijuana in the context of non-medical use as adolescents prior to becoming MMP. Becoming a mature MMP followed interactions with dispensary staff or further self-exploration of medical uses and often involved a social process that helped confirm the legitimacy of medical use and identity as a medical user. In some cases, MMP transitioned back to non-medical users as health conditions improved or remained primarily non-medical users even after becoming MMP for reasons unrelated to health, e.g., protection against arrest., Conclusion: Becoming a medical marijuana user was an important career trajectory that was influenced by early discoveries of effective medicinal use, interaction with proponents of medical use at dispensaries, experiences with new kinds of medical use, and the demands of particular health condition requiring more or less treatment with marijuana., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: Several studies suggest that U.S. state-level legalization of cannabis for medical purposes may be associated with reductions in opioid use; yet its relationship with stimulant use, particularly in high-risk populations like unstably housed women, has received less attention. The purpose of this study was to estimate independent associations between medical and non-medical use of cannabis and use of stimulants and opioids among unstably housed women., Methods: Cross-sectional data were analyzed from 245 women in the SHADOW study, a community based cohort in San Francisco, CA, in which HIV+ women were oversampled (126 HIV+ and 119 HIV-)., Results: Compared to no cannabis use in the past 6 months (51%), non-medical cannabis use (28%) was associated with a higher adjusted odds of using stimulants (Adjusted Odds Ratio [AOR]=4.34, 95% confidence interval [CI]: 2.17-8.70) and opioids (AOR=3.81, 95% CI: 1.78-8.15). Compared to no cannabis use, medical cannabis use (21%) was not significantly associated with stimulant or opioid use. Compared to non-medical cannabis use, however, medical cannabis use was associated with lower adjusted odds of using stimulants (AOR=0.42, 95% CI: 0.18-0.96). These associations were not modified by HIV status., Conclusions: Associations between use of cannabis and "street drugs" depend on whether the cannabis is obtained through a medical context. Interventions, research, and policy considering the influence of cannabis on the use of other drugs may benefit by distinguishing between medical and non-medical cannabis use., (Copyright © 2017. Published by Elsevier B.V.)

Background: Co-prescribing of scheduled drugs is endemic in the United Sates, increasing health risks to patients and the burden on healthcare systems., Purpose: We conducted a pragmatic historical cohort study to measure the effect of enrollment in a state-authorized United States' Medical Cannabis Program (MCP) on scheduled II-V drug prescription patterns., Procedures: Eighty-three chronic pain patients, who enrolled in the New Mexico MCP between April 1, 2010 and October 3, 2015, were compared with 42 nonenrolled patients over a 24-month period (starting 6 months before enrollment for the MCP patients) using the Prescription Monitoring Program. The outcome variables include baseline levels and pre- and postenrollment monthly trends in the number of drug prescriptions, distinct drug classes, dates prescription drugs were filled, and prescribing providers., Findings: Twenty-eight MCP patients (34%) and 1 comparison group patient (2%) ceased the use of all scheduled prescription medications by the last 6 months of the observation period. Age- and sex-adjusted regressions show that, although no statistically significant differences existed in pre-enrollment levels and trends, the postenrollment trend among MCP patients is statistically significantly negative for all 4 measures (decreases in counts of -0.02 to -0.04, P values between <.001 and .017), whereas the postenrollment trend is 0 among the comparison group. Controlling for time-invariant patient characteristics suggested that MCP patients showed statistically significantly lower levels across all 4 measures by 10 months postenrollment., Conclusions: Legal access to cannabis may reduce the use of multiple classes of dangerous prescription medications in certain patient populations., (Copyright © 2017 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Background: While medical marijuana use is legal in more than half of U.S. states, evidence is limited about the preparation of physicians-in-training to prescribe medical marijuana. We asked whether current medical school and graduate medical educational training prepare physicians to prescribe medical marijuana., Methods: We conducted a national survey of U.S. medical school curriculum deans, a similar survey of residents and fellows at Washington University in St. Louis, and a query of the Association of American Medical Colleges (AAMC) Curriculum Inventory database for keywords associated with medical marijuana., Results: Surveys were obtained from 101 curriculum deans, and 258 residents and fellows. 145 schools were included in the curriculum search. The majority of deans (66.7%) reported that their graduates were not at all prepared to prescribe medical marijuana, and 25.0% reported that their graduates were not at all prepared to answer questions about medical marijuana. The vast majority of residents and fellows (89.5%) felt not at all prepared to prescribe medical marijuana, while 35.3% felt not at all prepared to answer questions, and 84.9% reported receiving no education in medical school or residency on medical marijuana. Finally, only 9% of medical school curriculums document in the AAMC Curriculum Inventory database content on medical marijuana., Conclusions: Our study highlights a fundamental mismatch between the state-level legalization of medical marijuana and the lack of preparation of physicians-in-training to prescribe it. With even more states on the cusp of legalizing medical marijuana, physician training should adapt to encompass this new reality of medical practice., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Pain associated with integumentary wounds is highly prevalent, yet it remains an area of significant unmet need within health care. Currently, systemically administered opioids are the mainstay of treatment. However, recent publications are casting opioids in a negative light given their high side effect profile, inhibition of wound healing, and association with accidental overdose, incidents that are frequently fatal. Thus, novel analgesic strategies for wound-related pain need to be investigated. The ideal methods of pain relief for wound patients are modalities that are topical, lack systemic side effects, noninvasive, self-administered, and display rapid onset of analgesia. Extracts derived from the cannabis plant have been applied to wounds for thousands of years. The discovery of the human endocannabinoid system and its dominant presence throughout the integumentary system provides a valid and logical scientific platform to consider the use of topical cannabinoids for wounds. We are reporting a prospective case series of three patients with pyoderma gangrenosum that were treated with topical medical cannabis compounded in nongenetically modified organic sunflower oil. Clinically significant analgesia that was associated with reduced opioid utilization was noted in all three cases. Topical medical cannabis has the potential to improve pain management in patients suffering from wounds of all classes., (Copyright © 2017 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: To examine the prevalence and correlates of vaporization (i.e., "vaping") as a route of cannabis administration in a sample of medical cannabis patients., Procedures: Adults ages 21 and older (N=1485M age=45.1) who were seeking medical cannabis certification (either for the first time or as a renewal) at medical cannabis clinics in southern Michigan completed a screening assessment. Participants completed measures of route of cannabis administration, cannabis use, alcohol and other substance use., Findings: An estimated 39% (n=511) of the sample reported past-month cannabis vaping, but vaping as the sole route of cannabis administration was rare. Specifically, only 30 participants (2.3% of the full sample and 5.9% of those who reported any vaping) indicated vaping as the sole route of cannabis administration. The majority (87.3%) of those who reported vaping also reported smoking (combustion) as a route of cannabis administration. Being younger than age 44, having more than a high school education, engaging in nonmedical stimulant use, being a returning medical cannabis patient, and greater frequency of cannabis use were associated with higher odds of vaping at the bivariate level and with all variables considered simultaneously., Conclusions: Vaping appears to be relatively common among medical cannabis patients, but is seldom used as the sole route of cannabis administration., Results: highlight the importance of monitoring trends in vaping and other substance use behaviors in this population and underscore the need for longitudinal research into the motives, correlates, and consequences of cannabis vaping in medical cannabis patients., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Background: Medical marijuana legalization is associated with a higher prevalence of marijuana use which may affect cigarette use and nicotine dependence in co-users. In the present study, we examined relationships between statewide legalization of medical marijuana and prevalence of cigarette and marijuana co-use and nicotine dependence in co-using adolescents and adults., Methods: Data were analyzed from the 2013 National Survey on Drug Use and Health. We compared cigarette and marijuana co-use in the past 30days across age categories (12-64 years) by statewide medical marijuana legalization. Logistic regression models were used to estimate the odds of having nicotine dependence among current cigarette smokers who also reported past 30-day marijuana use and "ever but not current" marijuana use (vs. "never" use) adjusting for covariates including statewide legalization of medical marijuana., Results: Overall, 5.1% of the sample reported past 30-day cigarette and marijuana co-use and a higher proportion of co-users resided in states where medical marijuana was legal compared to illegal (5.8% vs. 4.8%; p=0.0011). Co-use was associated with greater odds of having nicotine dependence compared to cigarette-only use across age categories. Odds were highest and up to 3-times higher in adolescents aged 12-17 years (OR=3.54; 95%CI: 1.81-6.92) and adults aged 50-64 years (OR=3.08; CI: 1.45-6.55)., Conclusion: Marijuana policy could inadvertently affect cigarette and marijuana co-use and pose challenges to tobacco cessation., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

The purpose of this report is to present a review of the medical uses, efficacy, and adverse effects of the three approved cannabis-based medications and ingested marijuana. A literature review was conducted utilizing key search terms: dronabinol, nabilone, nabiximols, cannabis, marijuana, smoke, efficacy, toxicity, cancer, multiple sclerosis, nausea, vomiting, appetite, pain, glaucoma, and side effects. Abstracts of the included literature were reviewed, analyzed, and organized to identify the strength of evidence in medical use, efficacy, and adverse effects of the approved cannabis-based medications and medical marijuana. A total of 68 abstracts were included for review. Dronabinol's (Marinol) most common medical uses include weight gain, chemotherapy-induced nausea and vomiting (CINV), and neuropathic pain. Nabiximol's (Sativex) most common medical uses include spasticity in multiple sclerosis (MS) and neuropathic pain. Nabilone's (Cesamet) most common medical uses include CINV and neuropathic pain. Smoked marijuana's most common medical uses include neuropathic pain and glaucoma. Orally ingested marijuana's most common medical uses include improving sleep, reducing neuropathic pain, and seizure control in MS. In general, all of these agents share similar medical uses. The reported adverse effects of the three cannabis-based medications and marijuana show a major trend in central nervous system (CNS)-related adverse effects along with cardiovascular and respiratory related adverse effects. Marijuana shares similar medical uses with the approved cannabis-based medications dronabinol (Marinol), nabiximols (Sativex), and nabilone (Cesamet), but the efficacy of marijuana for these medical uses has not been fully determined due to limited and conflicting literature. Medical marijuana also has similar adverse effects as the FDA-approved cannabis-based medications mainly consisting of CNS related adverse effects but also including cardiovascular and respiratory related adverse effects. Finally, insufficient higher-order evidence to support the widespread use of medical marijuana was found, but a limited amount of moderate-level evidence supports its use in pain and seizure management., (Published by Elsevier Inc.)

Objectives: To determine the knowledge and training of Oregon Medical Marijuana Dispensary (OMMD) personnel and describe the information and type of advice provided to patients who use Oregon dispensaries., Methods: Statewide cross-sectional email survey of OMMD personnel., Results: Of the 141 surveys, 47 were initiated. The most frequently referenced types of training were on-the-job training and the Internet. Dispensary personnel most commonly used patients' preferences and symptoms as well as personal experiences to determine appropriate strains for patients. The majority of respondents advised patients about precautions and expected effects. Respondents were least likely to advise on drug interactions, or recommend a patient talk to a pharmacist or prescriber., Conclusion: Dispensary personnel in Oregon use a variety of resources to learn about medical marijuana. Although formal health or medical training was not indicated, personnel advise on marijuana's effects, use, and product selection. Further study is needed to assess the current training and advising on patients' ability to use medical marijuana safely and effectively., (Copyright © 2016 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.)

Purpose: To examine adolescents' annual use of medical marijuana and determine if legal medical marijuana users are at lower risk for frequent marijuana use and other substance use when compared to adolescents who use diverted medical marijuana or from an illicit source., Methods: Public access Monitoring the Future data were used for this secondary analysis. The total weighted sample size was 4394 12th graders., Results: Users of medical marijuana and diverted medical marijuana had notable odds of using daily, using prescription drugs, and using illicit drugs among other substance use behaviors. Medical marijuana users had much higher odds of using medical marijuana because of being "hooked" when compared to diverted medical users and illicit users., Conclusion: This study is the first to provide nationally representative data on three groups of adolescent marijuana users. Although most adolescents use illicit sources, more adolescents appear to be using diverted medical marijuana, than using medical marijuana legally., (Copyright © 2015 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Background: There is increasing debate about cannabis use for medical purposes, including for symptomatic treatment of chronic pain. We investigated patterns and correlates of cannabis use in a large community sample of people who had been prescribed opioids for chronic non-cancer pain., Methods: The POINT study included 1514 people in Australia who had been prescribed pharmaceutical opioids for chronic non-cancer pain. Data on cannabis use, ICD-10 cannabis use disorder and cannabis use for pain were collected. We explored associations between demographic, pain and other patient characteristics and cannabis use for pain., Results: One in six (16%) had used cannabis for pain relief, 6% in the previous month. A quarter reported that they would use it for pain relief if they had access. Those using cannabis for pain on average were younger, reported greater pain severity, greater interference from and poorer coping with pain, and more days out of role in the past year. They had been prescribed opioids for longer, were on higher opioid doses, and were more likely to be non-adherent with their opioid use. Those using cannabis for pain had higher pain interference after controlling for reported pain severity. Almost half (43%) of the sample had ever used cannabis for recreational purposes, and 12% of the entire cohort met criteria for an ICD-10 cannabis use disorder., Conclusions: Cannabis use for pain relief purposes appears common among people living with chronic non-cancer pain, and users report greater pain relief in combination with opioids than when opioids are used alone., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Purpose: The state-level legalization of medical marijuana has raised concerns about increased accessibility and appeal of the drug to youth. The objective of this study was to assess the impact of medical marijuana legalization across the United States by comparing trends in adolescent marijuana use between states with and without legalization of medical marijuana., Methods: The study utilized data from the Youth Risk Behavioral Surveillance Survey between 1991 and 2011. States with a medical marijuana law for which at least two cycles of Youth Risk Behavioral Surveillance data were available before and after the implementation of the law were selected for analysis. Each of these states was paired with a state in geographic proximity that had not implemented the law. Chi-squared analysis was used to compare characteristics between states with and without medical marijuana use policies. A difference-in-difference regression was performed to control for time-invariant factors relating to drug use in each state, isolating the policy effect, and then calculated the marginal probabilities of policy change on the binary dependent variable., Results: The estimation sample was 11,703,100 students. Across years and states, past-month marijuana use was common (20.9%, 95% confidence interval 20.3-21.4). There were no statistically significant differences in marijuana use before and after policy change for any state pairing. In the regression analysis, we did not find an overall increased probability of marijuana use related to the policy change (marginal probability .007, 95% confidence interval -.007, .02)., Conclusions: This study did not find increases in adolescent marijuana use related to legalization of medical marijuana., (Copyright © 2014 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)