http://informahealthcare.com/ada ISSN: 0095-2990 (print), 1097-9891 (electronic) Am J Drug Alcohol Abuse, Early Online: 1–7 ! 2014 Informa Healthcare USA, Inc. DOI: 10.3109/00952990.2014.949727
Use and diversion of medical marijuana among adults admitted to inpatient psychiatry Abraham M. Nussbaum, MD1, Christian Thurstone, MD1, Laurel McGarry, BA2, Brendan Walker, BA3, and Allison L. Sabel, MD, PhD, MPH4 Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by University of Calgary on 02/02/15 For personal use only.
1
Denver Health and Hospital Authority, CO, and the University of Colorado School of Medicine Department of Psychiatry, CO, 2University of Colorado School of Medicine, 3University of Colorado Denver, and 4Denver Health and Hospital Authority, CO, and the University of Colorado Denver Department of Biostatistics and Informatics, CO, USA Abstract
Keywords
Background: Marijuana use is associated with anxiety, depressive, psychotic, neurocognitive, and substance use disorders. Many US states are legalizing marijuana for medical uses. Objective: To determine the prevalence of medical marijuana use and diversion among psychiatric inpatients in Colorado. Methods: Some 623 participants (54.6% male) responded to an anonymous 15-item discharge survey that assessed age, gender, marijuana use, possession of a medical marijuana card, diversion of medical marijuana, perceived substance use problems, and effects of marijuana use. Univariate statistics were used to characterize participants and their responses. Chi-square tests assessed factors associated with medical marijuana registration. Results: Of the total number of respondents, 282 (47.6%) reported using marijuana in the last 12 months and 60 (15.1%) reported having a marijuana card. In comparison to survey respondents who denied having a medical marijuana card, those respondents with a medical marijuana card were more likely to have initiated use before the age of 25, to be male, to have used marijuana in the last 12 months, and to have used at least 20 days in the past month. 133 (24.1%) respondents reported that someone with a medical marijuana card had shared or sold medical marijuana to them; 24 (41.4%) of respondents with a medical marijuana card reported ever having shared or sold their medical marijuana. Conclusion: Medical marijuana use is much more prevalent among adults hospitalized with a psychiatric emergency than in the general population; diversion is common. Further studies which correlate amount, dose, duration, and strain of use with particular psychiatric disorders are needed.
Cannabis, diversion, inpatient psychiatry, medical marijuana, substance use, survey
Introduction Although the scientific inquiry into the health benefits and harms of marijuana is ongoing (1), this debate is being superseded in the United States by increased legal access to medical marijuana, which is now permitted in 20 states and the District of Columbia. Colorado, where the medical use of marijuana was permitted in 2000 and the recreational use was permitted in 2014, has the highest per-capita use of medical marijuana in the United States (2); over 2% of the state’s population is registered to use medical marijuana (3). To register a patient to use medical marijuana, a Colorado physician attests that a patient has one of eight qualifying conditions – cancer, cachexia, HIV/AIDS, glaucoma, epilepsy, muscle spasms, severe nausea, or severe pain. The registry does not require the failure of other treatments, or an Address correspondence to Abraham M. Nussbaum, MD, Director, Adult Inpatient Psychiatry Service, Denver Health, Assistant Professor of Psychiatry, University of Colorado School of Medicine, 777 Bannock Street, MC 0490, Denver, CO 80204-4507 USA. Tel: +1 303 602 6890. Fax: +1 303 602 6930. E-mail: [email protected]
History Received 21 February 2014 Revised 21 July 2014 Accepted 23 July 2014 Published online 6 November 2014
ongoing patient-physician relationship, and has no exclusion criteria or age requirements. The registry allows physicians to recommend, although not prescribe, marijuana to people with a ‘‘chronic or debilitating disease or medical condition’’ that ‘‘may be alleviated by the medical use of marijuana’’ (4). People recommended to use medical marijuana by a physician are anonymously registered with the Colorado Department of Public Health and the Environment (CDPHE). The CDPHE publishes aggregate demographics that show that the average age of registrants is 40 years, 69% of registrants are male, and 94% of patients are registered under the ‘‘severe pain’’ condition (2). At Denver Health, the city’s academic safety-net healthcare system, it is our clinical impression that the use of medical marijuana is prevalent among our patients. We have treated many patients with adverse events temporarily associated with medical marijuana use, especially psychiatric adverse events like suicide attempts (2). Marijuana is a complex psychoactive compound that has different effects on a user based on dose, strain, and formulation of marijuana, as well as a user’s previous exposure to marijuana. The chief
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psychoactive ingredient of marijuana, D-9-tetrahydrocannabinol, is a partial agonist at the brain’s endocannabinoid CB1 receptors, receptors that assist in the regulation of appetite, mood, and motivation (5). Researchers are exploring the potential therapeutic benefits of the multiple components of marijuana for conditions including neuropathic pain and spasms associated with multiple sclerosis (1). In addition, in surveys of marijuana users in the United Kingdom (6) and Canada (7), many respondents have characterized the anxiolytic and sedative properties of marijuana as salutary. At the same time, marijuana use is associated with several psychiatric adverse events. The World Health Organization names marijuana as the most commonly used illicit substance in the world (8). In the United States, approximately 6500 individuals begin using marijuana each day (9), and approximately 10% of users develop a cannabis use disorder (10). Among people admitted to substance treatment facilities in the United States, 17.1% identify marijuana as their primary substance of abuse (11). In addition to its association with substance use disorders, the regular use of marijuana is associated with the development of anxiety disorders (12), depressive disorders (13), suicidality (14), and cognitive decline (15) in several cohort studies and meta-analyses. The associations between marijuana use and psychiatric disorders have been extensively studied for psychotic disorders. In the resulting systematic reviews of epidemiologic and cohort data, the use of marijuana is significantly associated with an increased risk of developing schizophrenia at an earlier age (16), while other studies correlate marijuana use by persons with schizophrenia with impaired performance on tests of attention and impulsivity (17). While the biological mechanisms for the effects of marijuana are still being fully elucidated, the available literature suggests several mechanisms for the varieties of psychopathology often experienced by persons on an inpatient psychiatry unit. For example, activation of the endocannabinoid system increases impulsivity and suicidality, so the use of marijuana, which supplies exogenous cannabinoids, may increase impulsive acts and suicidal behavior, two common reasons for admission to a psychiatric facility (2). In animal models, marijuana use activates astroglial cannabinoid receptors in the hippocampus, which may explain the association in human marijuana users between bilateral volume reduction of the amygdala, hippocampus, and other brain structures involved in encoding memory (1); memory deficits are features of many disorders experienced by patients admitted to psychiatric facilities. Similarly, other animal models associate exogenous stimulation of the endocannabinoid system with impairment in GABA transmission, leading to enduring disinhibition in the prefrontal cortex (18). It is less clear to what extent the use of marijuana is related to the utilization of psychiatric resources like hospitalization. A recent prospective cohort study found that 30% of adults admitted for psychiatric hospitalization used marijuana in the 30 days before hospitalization, but the study was conducted in a location where the recreational and medical use of marijuana was illegal (19). To contextualize this finding, in the 2009 National Survey on Drug Use and Health, which measures drug use in the general population, 6.6% of persons age 12 or older report marijuana use in the month (9).
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While these are separate studies with different methodologies, the available evidence suggests that persons hospitalized for psychiatric treatment use marijuana at higher rates than the general population. At present, the currently published studies examining how persons with mental illness use medical marijuana have small sample sizes – a sample of 18 adults in California (20), and of 80 and 164 adolescents, respectively, in Colorado (21,22); all three studies were conducted after the legalization of the medical marijuana – and were conducted with persons enrolled in substance treatment programs. Finally, the diversion of medical marijuana has been previously described only in the Arizona Youth Survey, which found that 11.6% of 8th through 12th grade marijuana users had obtained their marijuana from someone with a medical marijuana card (23). While this survey showed that diversion of medical marijuana is prevalent, it did not obtain characteristics of those diverting medical marijuana, the survey was limited to adolescents, and it did not address persons hospitalized for psychiatric care. To test our clinical impressions that medical marijuana use is prevalent among our patients and to begin to address the known gaps in the literature – diversion by adults, use and diversion by persons hospitalized for psychiatric care, and small sample sizes – we initiated this study to, first, characterize the prevalence of medical marijuana use, the sharing or selling of medical marijuana by people registered to use medical marijuana, and the use of other people’s medical marijuana among a sample of adults admitted to an inpatient psychiatric service. Second, to determine if medical marijuana use, registration, or diversion correlates with a person’s age, gender, age of first marijuana use, selfperception of having a substance problem, past year marijuana use, and frequency of marijuana use. Third, to redress the research gap about the use and diversion of medical marijuana among persons requiring psychiatric hospitalization, in an initial effort to assess how the legalization of medical marijuana alters the use of psychiatric services. Since the use of marijuana is associated with substance use disorders and psychiatric disorders, we hypothesized, first, that registration to use medical marijuana would be prevalent among our respondents. Furthermore, we hypothesized, based on known patterns of marijuana use in Colorado, as reported by the CDPHE (2), and the associations between marijuana use and substance use disorders (12–17), that respondents who used and diverted medical marijuana would report more substance-related problems, earlier and more frequent use, and be more likely to be a man between the ages of 25 and 44, when compared to respondents who did not report the use and diversion of medical marijuana.
Methods Setting and participants Denver Health Medical Center provides psychiatric services through its ambulatory substance treatment facilities, psychiatry emergency service, and its inpatient units. Adults aged 18 years and older can be admitted to the adult inpatient psychiatric service, which is divided into two units of equal size. The west unit is for patients who require the availability
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of seclusion or restraint; the east unit is for less agitated patients. Patients often transfer to the east side before discharge, so approximately twice as many people discharged from the unit’s east side than from its west side during the study period. All patients discharged from the adult inpatient psychiatric units between 1 May 2011 and 31 May 2012 were eligible for this study. Participation was defined as willingness to complete at least one item on the survey. Patients were excluded if they were transferred to a correctional facility at discharge.
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Questionnaire and survey process Before the study began, the Colorado Multiple Institutional Review Board reviewed and approved the protocol and survey instrument. As part of the unit’s standard discharge process, patients meet with a staff nurse to review their continuing care plan. During the study period, the staff nurse asked each patient if he or she would participate in an anonymous survey assessing medical marijuana use and diversion. The questionnaire was based on prior research evaluating medical marijuana use and diversion among adolescents (21). Participants were informed about the study in writing and verbally. To allay fears of surveillance, the survey was administered on paper rather than on a computer. Out of concern that a lengthy survey would have a low completion rate, we limited our survey to a single printed page and focused our questions on a participant’s use, diversion, and experience with medical marijuana. Participants were reminded on the questionnaire itself that their participation was voluntary, anonymous, and not a part of their medical record. Participants received no compensation. Participants and staff were instructed not to write participant names on the questionnaire. If a person declined to answer the survey, the nurse was instructed to leave the survey blank, and no data was gathered on persons who declined to participate. If a person was willing to answer the survey, the person completed as much as they were willing to complete. If a person was unable to read, the discharging nurse read the survey to them. If a person was unable to read English, the survey was read to them with the assistance of a hospital interpreter or an interpreter language line. The completed survey was placed into a locked box mounted on the wall of each unit. The surveys were removed and stored in a locked cabinet until the study ended. As shown in Figure 1, the survey had a skip-pattern design where not all questions applied to every respondent, so we anticipated that each question would receive a different number of responses. Thus, our study results are reported based on the number of respondents to each question, which leads to an uneven number of subjects in comparison groups. If a participant denied having a medical marijuana card, any responses about the reasons, use, and medical visits related to medical marijuana were ignored. Statistical analyses Univariate statistics, including frequencies, percentages, medians, and interquartile ranges (IQR) were used to characterize the patients and their responses about medical marijuana use. All continuous variables were non-normally
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distributed based on the Anderson-Darling test (p50.01). Pearson Chi-square tests were used to determine risk factors associated with medical marijuana registrants. Cramer’s V was used to determine effect size. P values less than 0.05 were considered statistically significant and all analyses were done using SAS Software v9.2 (SAS Institute, Cary, NC, USA).
Results During the 13-month study period, a total of 1364 adults were discharged from the psychiatric units. Thirteen patients were ineligible for the study because they were discharged or transferred to correctional care. The east unit discharged 916 patients (67.8%) and the west unit discharged 435 patients (32.2%). There were similar numbers of females and males discharged (658 vs. 693, respectively). The median length of stay was 6 days on each unit (IQR 3–10 days for east unit, 3–12 days for west unit). Age was similar in the two units with a median of 38 years (IQR 28–51 years for east unit, 28–52 years for west unit). Approximately half (53.9%) of the discharged patients initially agreed to participate in the survey. Of these participants, 84.7% answered at least one question. Twothirds of the respondents (n ¼ 414, 66.5%) were from the east unit, but the participation rates for patients from the two units were similar. Among surveys with at least one question answered, the response rate on individual items ranged from 82.2% for age to 11.8% for number of times seen by the doctor who recommended marijuana. Based on the skip logic, 54.0% of respondents completed all appropriate questions with 62 respondents (8.4%) responding to all 15 items. Because of the skip logic, the resulting percentages are for varying number of respondents, so we report both the number and percentages of respondents. The highest survey participation was among young to middle-aged adults. Of those who participated, 383 (63.4%) were between 18 and 44 years. Of those who chose to participate in the survey, 332 (55%) were male (Table 1). Some 592 respondents (49.3%) self-reported problems with alcohol and/or drugs and 593 respondents (47.6%) reported marijuana use in the past 12 months. Only 133 respondents (22.5%) indicated they had never tried marijuana. Marijuana use was common in the 30 days before participation in the survey, as only 167 respondents (42%) indicated they had not used marijuana in the past 30 days. 133 respondents (24.1%) indicated they had received medical marijuana that was intended for another person. Sixty respondents (10%) reported having a medical marijuana card. Of the remaining participants, 337 (56%) replied that they did not have a medical marijuana card and 226 (37%) did not provide a response. The 337 participants without a medical marijuana card consist of both recreational marijuana users and non-users. Correlates of medical marijuana use were determined by the 397 total patients who responded (Table 2). Males were significantly more likely to be medical marijuana registrants (p ¼ 0.04). Registrants and non-registrants were of similar age and self-reported problem with alcohol or drugs at similar rates. The age of first marijuana use was significantly different between the cohorts even after accounting for those that had never used marijuana
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We are asking people if and how they use marijuana. You do not have to complete this survey. Your responses are private. They will not be part of your medical record. Thank you. 1 How old are you? 18-24 25-34 35-44 45-54 55-64 >65 2
Are you:
3
How old were you when you first used marijuana?
4
Have you ever had a problem with alcohol or drugs?
Yes
No
5
Have you used marijuana in the past twelve months?
Yes
No Then go to queson 15
6
How many days in the past month have you used marijuana?
7
Do you have a medical marijuana card?
8
Why did a doctor recommend marijuana for you?
9
How helpful has marijuana been?
10
Female Never used
0
0-14
1-4
Male 15-24
5-9
25-34
10-14
35-44
15-19
>20
No Then go to queson 15
Yes
HIV/AIDS, cancer, or glaucoma Very helpful
Seizures
How much me did the doctor spend with you during the visit when they recommended marijuana?
1-4 minutes
5-9 minutes
10-14 minutes
11
How many mes have you seen the doctor who recommended marijuana?
1
2
3
12
Have you had any side effects from marijuana?
Yes
No
13
Have you ever shared or sold your marijuana?
Yes
No
14
Did you use marijuana before geng your medical marijuana card?
Yes
No
15
Has someone with a medical marijuana card ever shared or sold their marijuana to you?
Yes
No
Helpful
>45
Nausea
Muscle spasms
Severe pain
Unsure
Unhelpful
Very unhelpful
15-19 minutes
20-24 minutes
>25 minutes
4
5
>6
Neither helpful nor unhelpful
Figure 1. Study questionnaire.
(p ¼ 0.03). A larger percentage of registrants did not try marijuana until 25 years old (13% vs. 4%). The use of marijuana within the past year was significantly higher for registrants compared to those who use it recreationally (97% vs. 64%, p50.001). Marijuana usage in the past month was significantly higher for medical marijuana registrants (p50.001), which is primarily due to the lack of use among many non-registrants. After excluding those who did not use marijuana, there was no significant difference in the number of days of marijuana use in the past month (p ¼ 0.07). There was no difference in the usage of medical marijuana that was intended for another person between the two cohorts. Respondents with a medical marijuana card were pleased with its benefits, with 34 respondents (58.6%) describing medical marijuana as ‘‘very helpful’’ and 18 respondents (31%) describing it as ‘‘helpful’’; only four respondents
(6.9%) described it as ‘‘very unhelpful’’ (Table 3). 44 respondents (73.3%) reported that they had not experienced side-effects from medical marijuana. Only five patients (8.3%) had never tried marijuana before getting their medical marijuana card. A total of 44 registrants (78.6%) indicated ‘‘severe pain’’ as the reason that a doctor recommended medical marijuana to them. Other common reasons included muscle spasms (n ¼ 18, 32.1%) and nausea (n ¼ 13, 23.2%). One registrant (1.8%) was unsure why the doctor recommended medical marijuana. Some 27 registrants (46.6%) reported spending at least 25 minutes with a doctor during the visit when medical marijuana was recommended. Only five registrants (8.3%) reported spending less than 10 minutes with the doctor. Twenty-four registrants (42.1%) reported only one visit with the doctor who recommended marijuana, however six patients
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Table 1. Survey responses.
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Question Unita East (less agitated patients) West (more agitated patients) Age 18–24 years 25–34 years 35–44 years 45–54 years 55–64 years 4¼65 years Male Age at first marijuana use never used 5¼14 years 15–24 years 25–34 years 35–44 years 4¼45 years Self-reports problem with alcohol/drugs Marijuana use in past 12 months Days of marijuana use in past month 0 days 1–4 days 5–9 days 10–14 days 15–19 days 4¼20 days Medical marijuana card Received medical marijuana intended for another person that you purchased or shared
Total responses to question
Frequency (percent)
623
414 (66.5) 209 (33.6)
604
117 151 115 132 71 18 322 133 203 232 15 5 4 292 282
(19.4) (25.0) (19.0) (21.9) (11.8) (3.0) (54.6) (22.5) (34.3) (39.2) (2.5) (0.8) (0.7) (49.3) (47.6)
167 107 33 21 14 56 60 133
(42.0) (26.9) (8.3) (5.3) (3.5) (14.1) (15.1) (24.1)
590 592
592 593 398
397 552
a
Determined by location of lock box where completed surveys were deposited.
(10.5%) reported at least six visits with the recommending physician.
Discussion Summary of findings The rate of registration for medical marijuana among our respondents was seven-fold that of the state’s general population. However, the age of registrants and the indication for which they reported being registered roughly correspond to the demographics maintained by the state’s registry (3). This may suggest that a disproportionate percentage of the people registered to use medical marijuana in Colorado have a psychiatric disorder and a history of alcohol- or drug-related problems. Since the use of marijuana has been associated with anxiety (12), depression (13), suicidality (14), cognitive decline (15), and psychosis (16), medical marijuana systems like Colorado’s may be increasing the use of expensive and scarce mental health resources like psychiatric hospitalization. Alternately, the high prevalence of medical marijuana registration may indicate salutary benefits for persons with mental illness. In the study, respondents with a medical marijuana card reported good efficacy and excellent tolerability of medical marijuana. In addition, a majority of these respondents, 70.7%, also reported spending at least 20 minutes with the physician who recommended medical marijuana. However, 66.7% of respondents with a medical marijuana card also reported seeing the doctor only once or twice, suggesting these relationships are not ongoing patient-
Table 2. Risk factors of medical marijuana registrants, Frequency (percent)a.
Risk factor West Unit (more agitated patients) Current age 18–24 years 25–34 years 35–44 years 45–54 years 55–64 years 4¼65 years Male Age at first marijuana use Never used 5¼14 years 15–24 years 4¼25 years Self-reports problem with alcohol/drugs Marijuana use in past 12 months Days of marijuana use in past month 0 days 1–4 days 5–9 days 10–14 days 15–19 days 4¼20 days Received medical marijuana intended for another person that you purchased or shared
5
MMJ registrant (n ¼ 60)
No MMJ card (n ¼ 337)
18 (30.0)
119 (35.3)
0.04
0.64
0.43
7 19 17 10 5 2 40
(11.7) (31.7) (28.3) (16.7) (8.3) (3.3) (69.0)
80 94 54 69 29 6 177
(24.1) (28.3) (16.3) (20.8) (8.7) (1.8) (54.5)
0.15
8.84
0.12
0.10
4.22
0.04
2 22 27 7 33 58
(3.5) (37.9) (46.6) (12.1) (55.0) (96.7)
41 127 147 11 172 213
(12.6) (39.0) (45.1) (3.4) (52.0) (64.2)
9 18 5 7 6 15 22
(15.0) (30.0) (8.3) (11.7) (10.0) (25.0) (37.3)
149 85 28 14 7 40 95
(46.1) (26.3) (8.7) (4.3) (2.2) (12.4) (31.8)
Cramer’s V
2
p Value
0.22
*
50.01
0.02 0.25
0.19 25.17
0.66 50.001
0.29
31.86
50.001
0.04
0.68
0.41
MMJ, medical marijuana. aMissing survey responses: 5 for current age, 14 for gender, 13 for age when first used marijuana, 6 for self-reported substance problem, 5 for marijuana in past year, 14 for marijuana in past month, 39 for received diverted medical marijuana. *Fisher’s exact test.
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Table 3. Medical marijuana registrants (n ¼ 60).
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Question Reason for medical marijuanaa Severe pain Muscle spasms Nausea HIV, cancer, or glaucoma Seizures Unsure Helpfulness of medical marijuanab Very helpful Helpful Neither helpful nor unhelpful Unhelpful Very unhelpful Time spent with doctor during visit when marijuana was recommendedb 1–4 minutes 5–9 minutes 10–14 minutes 15–19 minutes 20–24 minutes 4¼25 minutes Visits to doctor whom recommended marijuanac 1 2 3 4 5 4¼6 Side-effects of marijuanad Ever shared or sold your marijuanab Marijuana usage before getting medical marijuana card
Frequency (percent) 44 (78.6) 18 (32.1) 13 (23.2) 3 (5.4) 3 (5.4) 1 (1.8) 34 (58.6) 18 (31.0) 2 (3.5) 0 (0.0) 4 (6.9)
4 (6.9) 1 (1.7) 10 (17.2) 2 (3.5) 14 (24.1) 27 (46.6) 24 (42.1) 14 (24.6) 6 (10.5) 6 (10.5) 1 (1.8) 6 (10.5) 16 (27.1) 24 (41.4) 55 (91.7)
a
56 participants answered this item and they can indicate multiple reasons for medical marijuana; b2 participants did not answer this item; c 3 participants did not answer this item; d1 participant did not answer this item.
doctor relationships (3,24). The study suggests that many registrants are pleased with the state’s medical marijuana system. Among all respondents, the use of diverted medical marijuana was quite common, with almost a quarter of respondents reporting that someone with a medical marijuana card had shared or sold marijuana to them. Young men with a history of problems with alcohol or drugs who did not have a medical marijuana card were the most likely to report receiving diverted medical marijuana. Study limitations The generalizability of these findings is limited by collection of data from a single site. The sample may skew to people with lower socioeconomic status because of the hospital’s social mission, but socioeconomic data of respondents were not collected. Details about the legal status of the participants during their hospitalization and the mental illness for which they were treated are not available, though this information would help characterize persons using and diverting medical marijuana. Without complete demographic data, it is impossible to know how this study population compares to the larger sample of medical marijuana registrants in the state, but the available data suggests a concordance with what is known
about that sample. The study sample was clearly a clinical sample rather than a probability sample and does not represent the general population of Colorado. In addition, this study relies on self-report, so it suffers from sampling bias, and thus represents a subset of psychiatric patients who will voluntarily complete an anonymous discharge survey without compensation. Finally, the study instrument did not include psychometric data. In general, our survey was limited by the difficulties of studying the medical use of marijuana. Although permitted in Colorado, the use and possession of marijuana remains a federal crime. Given that we were surveying a vulnerable population, our survey was necessarily limited to preserve the anonymity of our participants. So we did not ask about socioeconomic data or particular diagnoses that could, in combination, compromise a participant’s anonymity. While the resulting survey instrument ably protects the anonymity of participants, it allows for no comparison between participants who did and did not respond to their survey, as well as the intriguing relationships between marijuana use and particular psychiatric disorders like anxiety, depressive, neurocognitive, and psychotic disorders that are associated with marijuana use. Instead, the survey was designed to ask different questions of groups with different exposure to marijuana, but its design appears to have ultimately reduced completion rates. Implications This survey has the largest sample size of any study of medical marijuana use and diversion among persons with mental illness and is the first study to assess the prevalence of use and diversion of medical marijuana among adults admitted to an inpatient psychiatry service. It finds that the use of medical marijuana is much higher than in Colorado’s general population, so the study reminds policy-makers to consider how the legalization of medical marijuana will affect mental health systems. Permitting the medical use of marijuana may benefit a subset of patients, and in further studies, it would be interesting to ask respondents to characterize how marijuana was helpful and how its benefits and tolerability compare to other treatments they receive. For other patients, the legalization of the medical use of marijuana may increase the need for mental health and substance treatment. It would be helpful, in further studies, to characterize these patients so that policy-makers can determine how to spend medical marijuana tax revenue earmarked for mental health and substance treatment. In Colorado, this revenue has exceeded expectations and the recent legalization of the recreational use of marijuana may ultimately create an additional $100 million of tax revenue per year, a portion of which is expected to be spent on substance and mental health treatment (25). At present, policy-makers have targeted prevention efforts and exclusion criteria at adolescents, because the harms of regular marijuana use are most consistently associated with early and persistent use beginning in adolescence (26); this study offers support for such interventions because only 4% of respondents in our study initiated use of marijuana after the age of 25. However, this study suggests the need to better characterize who is harmed and who benefits from increased access to medical marijuana so that public funds can we be well-used.
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DOI: 10.3109/00952990.2014.949727
In addition, our study is the first to document diversion of medical marijuana among adults. While our study sample has the limitations described above, it also documents that at least some persons registered to share medical marijuana are sharing or selling their medical marijuana with others. For clinicians interested in knowing if a patient is using medical marijuana, it is insufficient to ask if they registered to use medical marijuana; they should also inquire if someone else shares or sells medical marijuana to them. Researchers should continue to explore the associations between mental illness and cannabis use, as this study demonstrates a higher use of medical marijuana among persons hospitalized with mental illness than in the general population. In future studies, it is critical to better characterize both participants – especially with regards to their patterns of use, socioeconomic status, and particular psychiatric disorders – and the type of marijuana they use. Marijuana is a complex substance and in future studies, it is critical to assess the amount, dose, duration, and strain of marijuana used by participants. In addition, researchers should explore whether or not the advertising of the medical marijuana industry targets people with mental illnesses, as persons with mental illness have been historically targeted by the tobacco industry (27). In doing so, further studies could better characterize when (and how) the medical use of marijuana is harmful and helpful, for persons with mental illnesses.
Acknowledgements We thank Denver Health for encouraging this project and the staff nurses for administering the discharge questionnaire.
Declaration of interest The authors received no funding for this study or the preparation of this paper. Dr Nussbaum receives research support from the University of Chicago and royalties from American Psychiatric Publishing for unrelated projects. Dr Thurstone receives research support from NIDA Grant R01DA201913-04, U10DA013045, U10DA013045-11S3, and R01DA031816-01A1. Ms McGarry and Mr Walker have no relationships to disclose. Dr Sabel receives research support from NIAID, CMMI Health Care Innovation, and High Value Healthcare Collaborative for unrelated projects. The authors alone are responsible for the content and writing of this paper.
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6. Ware MA, Adams H, Guy GW. The medicinal use of cannabis in the UK: results of a nationwide survey. Int J Clin Pract 2005;59: 291–295. 7. Walsh Z, Callaway R, Belle-Isle L, Capler R, Kay R, Lucas P, Holtzman S. Cannabis for therapeutic purposes: patient characteristics, access, and reasons for use. Int J Drug Policy 2013;24: 511–516. 8. United Nations Office on Drugs and Crime (UNODC). World Drug Report. United Nations publication, Sales No. E.12.XI.1, 2012. 9. Substance Abuse and Mental Health Services Administration. Results from the 2009 National Survey on Drug Use and Health: Volume I. Summary of National Findings. Office of Applied Studies, NSDUH Series H-38A, HHS Publication No. SMA 104586 Findings. Rockville, MD; 2010. 10. Hall W, Pacula RK. Cannabis use and dependence: public health and public policy. Cambridge, UK: Cambridge University Press; 2003. 11. United States Department of Health and Human Services. Substance Abuse and Mental Health Services Administration. Office of Applied Studies. Treatment Episode Data Set – Admissions (TEDS-A), 2008 [Computer file]. ICPSR27241-v2. Ann Arbor, MI: Inter-university Consortium for Political and Social Research [distributor], 2010-03-31; 2008. 12. van Laar M, van Dorsselaer S, Monshouwer K, de Graaf R. Does cannabis use predict the first incidence of mood and anxiety disorders in the adult population? Addiction 2007;102:1251–1260. 13. Degenhardt L, Hall W, Lynskey M. Exploring the association between cannabis use and depression. Addiction 2003;98: 1493–1504. 14. Pedersen W. Does cannabis use lead to depression and suicidal behaviors? A populations-based longitudinal study. Acta Psychiatr Scand 2008;118:395–403. 15. Meier MH, Caspi A, Ambler A, Harrington HJ, Houts R, Keefe RSE, McDonald K, et al. Persistent cannabis users show neuropsychological decline from childhood to midlife. Proc Natl Acad Sci USA 2012;109:E2657–E2664. 16. Large M, Sharma S, Comptom MT, Slade T, Nielssen O. Cannabis use and earlier onset of psychosis: a systematic meta-analysis. Arch Gen Psychiatry 2011;68:555–561. 17. Lev-Ran S, Segev A, Braw Y, Levkovitz Y. Neurocognitive functions of heavy cannabis using schizophrenia patients. Eur Psychiatry 2012;27:365–368. 18. Cass DK, Flores-Barrera E, Thomases DR, Vital WF, Caballero A, Tseng KY. CB1 cannabinoid receptor stimulation during adolescence impairs the maturation of GABA function in the adult rat prefrontal cortex. Mol Psychiatry 2014;19:536–543. 19. Bahorik AL, Newhill CE, Eack SM. Characterizing the longitudinal patterns of substance use among individuals diagnosed with serious mental illness after psychiatric hospitalization. Addiction 2013;108: 1259–1269. 20. Swartz R. Medical marijuana users in substance abuse treatment. Harm Reduct J 2010;7(1):3. 21. Thurstone C, Lieberman SA, Schmiege SJ. Medical marijuana diversion and associated problems in adolescent substance treatment. Drug Alcohol Depend 2011;118:489–492. 22. Salomonsen-Sautel S, Sakai JT, Thurstone C, Corley R, Hopfer C. Medical marijuana use among adolescents in substance abuse treatment. J Am Acad Child Adolesc Psychiatry 2012;51:694–702. 23. Arizona Criminal Justice Commission. Arizona Youth Survey State Report 2012. Available at: http://www.azrapeprevention.org/sites/ azrapeprevention.org/files/AYS%202012%20Report%20Final% 2012%2031%202012_0.pdf [last accessed 21 Feb 2014]. 24. Kondrad EC, Reid A. Colorado family physician’s attitudes toward medical marijuana. J Am Board Fam Med 2013;26:52–60. 25. Ingold J. Hickenlooper: $1 billion in pot sales expected next fiscal year. Denver Post, 19 February 2014. Available at: http:// www.thecannabist.co/2014/02/19/john-hickenlooper-coloradogoversnor-marijuana-tax-money-exceeds-expectations/5087/ [last accessed 21 Feb 2014]. 26. Gonzalez R, Swanson JM. Long-term effects of adolescent-onset and persistent use of cannabis. Proc Natl Acad Sci USA 2012;109: 15970–15971. 27. Prochaska JJ, Hall SM, Bero LA. Tobacco use among individuals with schizophrenia: what role has the tobacco industry played? Schizophr Bull 2008;34:555–567.
Use and diversion of medical marijuana among adults admitted to inpatient psychiatry Abraham M. Nussbaum, MD1, Christian Thurstone, MD1, Laurel McGarry, BA2, Brendan Walker, BA3, and Allison L. Sabel, MD, PhD, MPH4 Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by University of Calgary on 02/02/15 For personal use only.
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Denver Health and Hospital Authority, CO, and the University of Colorado School of Medicine Department of Psychiatry, CO, 2University of Colorado School of Medicine, 3University of Colorado Denver, and 4Denver Health and Hospital Authority, CO, and the University of Colorado Denver Department of Biostatistics and Informatics, CO, USA Abstract
Keywords
Background: Marijuana use is associated with anxiety, depressive, psychotic, neurocognitive, and substance use disorders. Many US states are legalizing marijuana for medical uses. Objective: To determine the prevalence of medical marijuana use and diversion among psychiatric inpatients in Colorado. Methods: Some 623 participants (54.6% male) responded to an anonymous 15-item discharge survey that assessed age, gender, marijuana use, possession of a medical marijuana card, diversion of medical marijuana, perceived substance use problems, and effects of marijuana use. Univariate statistics were used to characterize participants and their responses. Chi-square tests assessed factors associated with medical marijuana registration. Results: Of the total number of respondents, 282 (47.6%) reported using marijuana in the last 12 months and 60 (15.1%) reported having a marijuana card. In comparison to survey respondents who denied having a medical marijuana card, those respondents with a medical marijuana card were more likely to have initiated use before the age of 25, to be male, to have used marijuana in the last 12 months, and to have used at least 20 days in the past month. 133 (24.1%) respondents reported that someone with a medical marijuana card had shared or sold medical marijuana to them; 24 (41.4%) of respondents with a medical marijuana card reported ever having shared or sold their medical marijuana. Conclusion: Medical marijuana use is much more prevalent among adults hospitalized with a psychiatric emergency than in the general population; diversion is common. Further studies which correlate amount, dose, duration, and strain of use with particular psychiatric disorders are needed.
Cannabis, diversion, inpatient psychiatry, medical marijuana, substance use, survey
Introduction Although the scientific inquiry into the health benefits and harms of marijuana is ongoing (1), this debate is being superseded in the United States by increased legal access to medical marijuana, which is now permitted in 20 states and the District of Columbia. Colorado, where the medical use of marijuana was permitted in 2000 and the recreational use was permitted in 2014, has the highest per-capita use of medical marijuana in the United States (2); over 2% of the state’s population is registered to use medical marijuana (3). To register a patient to use medical marijuana, a Colorado physician attests that a patient has one of eight qualifying conditions – cancer, cachexia, HIV/AIDS, glaucoma, epilepsy, muscle spasms, severe nausea, or severe pain. The registry does not require the failure of other treatments, or an Address correspondence to Abraham M. Nussbaum, MD, Director, Adult Inpatient Psychiatry Service, Denver Health, Assistant Professor of Psychiatry, University of Colorado School of Medicine, 777 Bannock Street, MC 0490, Denver, CO 80204-4507 USA. Tel: +1 303 602 6890. Fax: +1 303 602 6930. E-mail: [email protected]
History Received 21 February 2014 Revised 21 July 2014 Accepted 23 July 2014 Published online 6 November 2014
ongoing patient-physician relationship, and has no exclusion criteria or age requirements. The registry allows physicians to recommend, although not prescribe, marijuana to people with a ‘‘chronic or debilitating disease or medical condition’’ that ‘‘may be alleviated by the medical use of marijuana’’ (4). People recommended to use medical marijuana by a physician are anonymously registered with the Colorado Department of Public Health and the Environment (CDPHE). The CDPHE publishes aggregate demographics that show that the average age of registrants is 40 years, 69% of registrants are male, and 94% of patients are registered under the ‘‘severe pain’’ condition (2). At Denver Health, the city’s academic safety-net healthcare system, it is our clinical impression that the use of medical marijuana is prevalent among our patients. We have treated many patients with adverse events temporarily associated with medical marijuana use, especially psychiatric adverse events like suicide attempts (2). Marijuana is a complex psychoactive compound that has different effects on a user based on dose, strain, and formulation of marijuana, as well as a user’s previous exposure to marijuana. The chief
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psychoactive ingredient of marijuana, D-9-tetrahydrocannabinol, is a partial agonist at the brain’s endocannabinoid CB1 receptors, receptors that assist in the regulation of appetite, mood, and motivation (5). Researchers are exploring the potential therapeutic benefits of the multiple components of marijuana for conditions including neuropathic pain and spasms associated with multiple sclerosis (1). In addition, in surveys of marijuana users in the United Kingdom (6) and Canada (7), many respondents have characterized the anxiolytic and sedative properties of marijuana as salutary. At the same time, marijuana use is associated with several psychiatric adverse events. The World Health Organization names marijuana as the most commonly used illicit substance in the world (8). In the United States, approximately 6500 individuals begin using marijuana each day (9), and approximately 10% of users develop a cannabis use disorder (10). Among people admitted to substance treatment facilities in the United States, 17.1% identify marijuana as their primary substance of abuse (11). In addition to its association with substance use disorders, the regular use of marijuana is associated with the development of anxiety disorders (12), depressive disorders (13), suicidality (14), and cognitive decline (15) in several cohort studies and meta-analyses. The associations between marijuana use and psychiatric disorders have been extensively studied for psychotic disorders. In the resulting systematic reviews of epidemiologic and cohort data, the use of marijuana is significantly associated with an increased risk of developing schizophrenia at an earlier age (16), while other studies correlate marijuana use by persons with schizophrenia with impaired performance on tests of attention and impulsivity (17). While the biological mechanisms for the effects of marijuana are still being fully elucidated, the available literature suggests several mechanisms for the varieties of psychopathology often experienced by persons on an inpatient psychiatry unit. For example, activation of the endocannabinoid system increases impulsivity and suicidality, so the use of marijuana, which supplies exogenous cannabinoids, may increase impulsive acts and suicidal behavior, two common reasons for admission to a psychiatric facility (2). In animal models, marijuana use activates astroglial cannabinoid receptors in the hippocampus, which may explain the association in human marijuana users between bilateral volume reduction of the amygdala, hippocampus, and other brain structures involved in encoding memory (1); memory deficits are features of many disorders experienced by patients admitted to psychiatric facilities. Similarly, other animal models associate exogenous stimulation of the endocannabinoid system with impairment in GABA transmission, leading to enduring disinhibition in the prefrontal cortex (18). It is less clear to what extent the use of marijuana is related to the utilization of psychiatric resources like hospitalization. A recent prospective cohort study found that 30% of adults admitted for psychiatric hospitalization used marijuana in the 30 days before hospitalization, but the study was conducted in a location where the recreational and medical use of marijuana was illegal (19). To contextualize this finding, in the 2009 National Survey on Drug Use and Health, which measures drug use in the general population, 6.6% of persons age 12 or older report marijuana use in the month (9).
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While these are separate studies with different methodologies, the available evidence suggests that persons hospitalized for psychiatric treatment use marijuana at higher rates than the general population. At present, the currently published studies examining how persons with mental illness use medical marijuana have small sample sizes – a sample of 18 adults in California (20), and of 80 and 164 adolescents, respectively, in Colorado (21,22); all three studies were conducted after the legalization of the medical marijuana – and were conducted with persons enrolled in substance treatment programs. Finally, the diversion of medical marijuana has been previously described only in the Arizona Youth Survey, which found that 11.6% of 8th through 12th grade marijuana users had obtained their marijuana from someone with a medical marijuana card (23). While this survey showed that diversion of medical marijuana is prevalent, it did not obtain characteristics of those diverting medical marijuana, the survey was limited to adolescents, and it did not address persons hospitalized for psychiatric care. To test our clinical impressions that medical marijuana use is prevalent among our patients and to begin to address the known gaps in the literature – diversion by adults, use and diversion by persons hospitalized for psychiatric care, and small sample sizes – we initiated this study to, first, characterize the prevalence of medical marijuana use, the sharing or selling of medical marijuana by people registered to use medical marijuana, and the use of other people’s medical marijuana among a sample of adults admitted to an inpatient psychiatric service. Second, to determine if medical marijuana use, registration, or diversion correlates with a person’s age, gender, age of first marijuana use, selfperception of having a substance problem, past year marijuana use, and frequency of marijuana use. Third, to redress the research gap about the use and diversion of medical marijuana among persons requiring psychiatric hospitalization, in an initial effort to assess how the legalization of medical marijuana alters the use of psychiatric services. Since the use of marijuana is associated with substance use disorders and psychiatric disorders, we hypothesized, first, that registration to use medical marijuana would be prevalent among our respondents. Furthermore, we hypothesized, based on known patterns of marijuana use in Colorado, as reported by the CDPHE (2), and the associations between marijuana use and substance use disorders (12–17), that respondents who used and diverted medical marijuana would report more substance-related problems, earlier and more frequent use, and be more likely to be a man between the ages of 25 and 44, when compared to respondents who did not report the use and diversion of medical marijuana.
Methods Setting and participants Denver Health Medical Center provides psychiatric services through its ambulatory substance treatment facilities, psychiatry emergency service, and its inpatient units. Adults aged 18 years and older can be admitted to the adult inpatient psychiatric service, which is divided into two units of equal size. The west unit is for patients who require the availability
Use and diversion of medical marijuana
DOI: 10.3109/00952990.2014.949727
of seclusion or restraint; the east unit is for less agitated patients. Patients often transfer to the east side before discharge, so approximately twice as many people discharged from the unit’s east side than from its west side during the study period. All patients discharged from the adult inpatient psychiatric units between 1 May 2011 and 31 May 2012 were eligible for this study. Participation was defined as willingness to complete at least one item on the survey. Patients were excluded if they were transferred to a correctional facility at discharge.
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Questionnaire and survey process Before the study began, the Colorado Multiple Institutional Review Board reviewed and approved the protocol and survey instrument. As part of the unit’s standard discharge process, patients meet with a staff nurse to review their continuing care plan. During the study period, the staff nurse asked each patient if he or she would participate in an anonymous survey assessing medical marijuana use and diversion. The questionnaire was based on prior research evaluating medical marijuana use and diversion among adolescents (21). Participants were informed about the study in writing and verbally. To allay fears of surveillance, the survey was administered on paper rather than on a computer. Out of concern that a lengthy survey would have a low completion rate, we limited our survey to a single printed page and focused our questions on a participant’s use, diversion, and experience with medical marijuana. Participants were reminded on the questionnaire itself that their participation was voluntary, anonymous, and not a part of their medical record. Participants received no compensation. Participants and staff were instructed not to write participant names on the questionnaire. If a person declined to answer the survey, the nurse was instructed to leave the survey blank, and no data was gathered on persons who declined to participate. If a person was willing to answer the survey, the person completed as much as they were willing to complete. If a person was unable to read, the discharging nurse read the survey to them. If a person was unable to read English, the survey was read to them with the assistance of a hospital interpreter or an interpreter language line. The completed survey was placed into a locked box mounted on the wall of each unit. The surveys were removed and stored in a locked cabinet until the study ended. As shown in Figure 1, the survey had a skip-pattern design where not all questions applied to every respondent, so we anticipated that each question would receive a different number of responses. Thus, our study results are reported based on the number of respondents to each question, which leads to an uneven number of subjects in comparison groups. If a participant denied having a medical marijuana card, any responses about the reasons, use, and medical visits related to medical marijuana were ignored. Statistical analyses Univariate statistics, including frequencies, percentages, medians, and interquartile ranges (IQR) were used to characterize the patients and their responses about medical marijuana use. All continuous variables were non-normally
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distributed based on the Anderson-Darling test (p50.01). Pearson Chi-square tests were used to determine risk factors associated with medical marijuana registrants. Cramer’s V was used to determine effect size. P values less than 0.05 were considered statistically significant and all analyses were done using SAS Software v9.2 (SAS Institute, Cary, NC, USA).
Results During the 13-month study period, a total of 1364 adults were discharged from the psychiatric units. Thirteen patients were ineligible for the study because they were discharged or transferred to correctional care. The east unit discharged 916 patients (67.8%) and the west unit discharged 435 patients (32.2%). There were similar numbers of females and males discharged (658 vs. 693, respectively). The median length of stay was 6 days on each unit (IQR 3–10 days for east unit, 3–12 days for west unit). Age was similar in the two units with a median of 38 years (IQR 28–51 years for east unit, 28–52 years for west unit). Approximately half (53.9%) of the discharged patients initially agreed to participate in the survey. Of these participants, 84.7% answered at least one question. Twothirds of the respondents (n ¼ 414, 66.5%) were from the east unit, but the participation rates for patients from the two units were similar. Among surveys with at least one question answered, the response rate on individual items ranged from 82.2% for age to 11.8% for number of times seen by the doctor who recommended marijuana. Based on the skip logic, 54.0% of respondents completed all appropriate questions with 62 respondents (8.4%) responding to all 15 items. Because of the skip logic, the resulting percentages are for varying number of respondents, so we report both the number and percentages of respondents. The highest survey participation was among young to middle-aged adults. Of those who participated, 383 (63.4%) were between 18 and 44 years. Of those who chose to participate in the survey, 332 (55%) were male (Table 1). Some 592 respondents (49.3%) self-reported problems with alcohol and/or drugs and 593 respondents (47.6%) reported marijuana use in the past 12 months. Only 133 respondents (22.5%) indicated they had never tried marijuana. Marijuana use was common in the 30 days before participation in the survey, as only 167 respondents (42%) indicated they had not used marijuana in the past 30 days. 133 respondents (24.1%) indicated they had received medical marijuana that was intended for another person. Sixty respondents (10%) reported having a medical marijuana card. Of the remaining participants, 337 (56%) replied that they did not have a medical marijuana card and 226 (37%) did not provide a response. The 337 participants without a medical marijuana card consist of both recreational marijuana users and non-users. Correlates of medical marijuana use were determined by the 397 total patients who responded (Table 2). Males were significantly more likely to be medical marijuana registrants (p ¼ 0.04). Registrants and non-registrants were of similar age and self-reported problem with alcohol or drugs at similar rates. The age of first marijuana use was significantly different between the cohorts even after accounting for those that had never used marijuana
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We are asking people if and how they use marijuana. You do not have to complete this survey. Your responses are private. They will not be part of your medical record. Thank you. 1 How old are you? 18-24 25-34 35-44 45-54 55-64 >65 2
Are you:
3
How old were you when you first used marijuana?
4
Have you ever had a problem with alcohol or drugs?
Yes
No
5
Have you used marijuana in the past twelve months?
Yes
No Then go to queson 15
6
How many days in the past month have you used marijuana?
7
Do you have a medical marijuana card?
8
Why did a doctor recommend marijuana for you?
9
How helpful has marijuana been?
10
Female Never used
0
0-14
1-4
Male 15-24
5-9
25-34
10-14
35-44
15-19
>20
No Then go to queson 15
Yes
HIV/AIDS, cancer, or glaucoma Very helpful
Seizures
How much me did the doctor spend with you during the visit when they recommended marijuana?
1-4 minutes
5-9 minutes
10-14 minutes
11
How many mes have you seen the doctor who recommended marijuana?
1
2
3
12
Have you had any side effects from marijuana?
Yes
No
13
Have you ever shared or sold your marijuana?
Yes
No
14
Did you use marijuana before geng your medical marijuana card?
Yes
No
15
Has someone with a medical marijuana card ever shared or sold their marijuana to you?
Yes
No
Helpful
>45
Nausea
Muscle spasms
Severe pain
Unsure
Unhelpful
Very unhelpful
15-19 minutes
20-24 minutes
>25 minutes
4
5
>6
Neither helpful nor unhelpful
Figure 1. Study questionnaire.
(p ¼ 0.03). A larger percentage of registrants did not try marijuana until 25 years old (13% vs. 4%). The use of marijuana within the past year was significantly higher for registrants compared to those who use it recreationally (97% vs. 64%, p50.001). Marijuana usage in the past month was significantly higher for medical marijuana registrants (p50.001), which is primarily due to the lack of use among many non-registrants. After excluding those who did not use marijuana, there was no significant difference in the number of days of marijuana use in the past month (p ¼ 0.07). There was no difference in the usage of medical marijuana that was intended for another person between the two cohorts. Respondents with a medical marijuana card were pleased with its benefits, with 34 respondents (58.6%) describing medical marijuana as ‘‘very helpful’’ and 18 respondents (31%) describing it as ‘‘helpful’’; only four respondents
(6.9%) described it as ‘‘very unhelpful’’ (Table 3). 44 respondents (73.3%) reported that they had not experienced side-effects from medical marijuana. Only five patients (8.3%) had never tried marijuana before getting their medical marijuana card. A total of 44 registrants (78.6%) indicated ‘‘severe pain’’ as the reason that a doctor recommended medical marijuana to them. Other common reasons included muscle spasms (n ¼ 18, 32.1%) and nausea (n ¼ 13, 23.2%). One registrant (1.8%) was unsure why the doctor recommended medical marijuana. Some 27 registrants (46.6%) reported spending at least 25 minutes with a doctor during the visit when medical marijuana was recommended. Only five registrants (8.3%) reported spending less than 10 minutes with the doctor. Twenty-four registrants (42.1%) reported only one visit with the doctor who recommended marijuana, however six patients
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Table 1. Survey responses.
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Question Unita East (less agitated patients) West (more agitated patients) Age 18–24 years 25–34 years 35–44 years 45–54 years 55–64 years 4¼65 years Male Age at first marijuana use never used 5¼14 years 15–24 years 25–34 years 35–44 years 4¼45 years Self-reports problem with alcohol/drugs Marijuana use in past 12 months Days of marijuana use in past month 0 days 1–4 days 5–9 days 10–14 days 15–19 days 4¼20 days Medical marijuana card Received medical marijuana intended for another person that you purchased or shared
Total responses to question
Frequency (percent)
623
414 (66.5) 209 (33.6)
604
117 151 115 132 71 18 322 133 203 232 15 5 4 292 282
(19.4) (25.0) (19.0) (21.9) (11.8) (3.0) (54.6) (22.5) (34.3) (39.2) (2.5) (0.8) (0.7) (49.3) (47.6)
167 107 33 21 14 56 60 133
(42.0) (26.9) (8.3) (5.3) (3.5) (14.1) (15.1) (24.1)
590 592
592 593 398
397 552
a
Determined by location of lock box where completed surveys were deposited.
(10.5%) reported at least six visits with the recommending physician.
Discussion Summary of findings The rate of registration for medical marijuana among our respondents was seven-fold that of the state’s general population. However, the age of registrants and the indication for which they reported being registered roughly correspond to the demographics maintained by the state’s registry (3). This may suggest that a disproportionate percentage of the people registered to use medical marijuana in Colorado have a psychiatric disorder and a history of alcohol- or drug-related problems. Since the use of marijuana has been associated with anxiety (12), depression (13), suicidality (14), cognitive decline (15), and psychosis (16), medical marijuana systems like Colorado’s may be increasing the use of expensive and scarce mental health resources like psychiatric hospitalization. Alternately, the high prevalence of medical marijuana registration may indicate salutary benefits for persons with mental illness. In the study, respondents with a medical marijuana card reported good efficacy and excellent tolerability of medical marijuana. In addition, a majority of these respondents, 70.7%, also reported spending at least 20 minutes with the physician who recommended medical marijuana. However, 66.7% of respondents with a medical marijuana card also reported seeing the doctor only once or twice, suggesting these relationships are not ongoing patient-
Table 2. Risk factors of medical marijuana registrants, Frequency (percent)a.
Risk factor West Unit (more agitated patients) Current age 18–24 years 25–34 years 35–44 years 45–54 years 55–64 years 4¼65 years Male Age at first marijuana use Never used 5¼14 years 15–24 years 4¼25 years Self-reports problem with alcohol/drugs Marijuana use in past 12 months Days of marijuana use in past month 0 days 1–4 days 5–9 days 10–14 days 15–19 days 4¼20 days Received medical marijuana intended for another person that you purchased or shared
5
MMJ registrant (n ¼ 60)
No MMJ card (n ¼ 337)
18 (30.0)
119 (35.3)
0.04
0.64
0.43
7 19 17 10 5 2 40
(11.7) (31.7) (28.3) (16.7) (8.3) (3.3) (69.0)
80 94 54 69 29 6 177
(24.1) (28.3) (16.3) (20.8) (8.7) (1.8) (54.5)
0.15
8.84
0.12
0.10
4.22
0.04
2 22 27 7 33 58
(3.5) (37.9) (46.6) (12.1) (55.0) (96.7)
41 127 147 11 172 213
(12.6) (39.0) (45.1) (3.4) (52.0) (64.2)
9 18 5 7 6 15 22
(15.0) (30.0) (8.3) (11.7) (10.0) (25.0) (37.3)
149 85 28 14 7 40 95
(46.1) (26.3) (8.7) (4.3) (2.2) (12.4) (31.8)
Cramer’s V
2
p Value
0.22
*
50.01
0.02 0.25
0.19 25.17
0.66 50.001
0.29
31.86
50.001
0.04
0.68
0.41
MMJ, medical marijuana. aMissing survey responses: 5 for current age, 14 for gender, 13 for age when first used marijuana, 6 for self-reported substance problem, 5 for marijuana in past year, 14 for marijuana in past month, 39 for received diverted medical marijuana. *Fisher’s exact test.
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Table 3. Medical marijuana registrants (n ¼ 60).
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Question Reason for medical marijuanaa Severe pain Muscle spasms Nausea HIV, cancer, or glaucoma Seizures Unsure Helpfulness of medical marijuanab Very helpful Helpful Neither helpful nor unhelpful Unhelpful Very unhelpful Time spent with doctor during visit when marijuana was recommendedb 1–4 minutes 5–9 minutes 10–14 minutes 15–19 minutes 20–24 minutes 4¼25 minutes Visits to doctor whom recommended marijuanac 1 2 3 4 5 4¼6 Side-effects of marijuanad Ever shared or sold your marijuanab Marijuana usage before getting medical marijuana card
Frequency (percent) 44 (78.6) 18 (32.1) 13 (23.2) 3 (5.4) 3 (5.4) 1 (1.8) 34 (58.6) 18 (31.0) 2 (3.5) 0 (0.0) 4 (6.9)
4 (6.9) 1 (1.7) 10 (17.2) 2 (3.5) 14 (24.1) 27 (46.6) 24 (42.1) 14 (24.6) 6 (10.5) 6 (10.5) 1 (1.8) 6 (10.5) 16 (27.1) 24 (41.4) 55 (91.7)
a
56 participants answered this item and they can indicate multiple reasons for medical marijuana; b2 participants did not answer this item; c 3 participants did not answer this item; d1 participant did not answer this item.
doctor relationships (3,24). The study suggests that many registrants are pleased with the state’s medical marijuana system. Among all respondents, the use of diverted medical marijuana was quite common, with almost a quarter of respondents reporting that someone with a medical marijuana card had shared or sold marijuana to them. Young men with a history of problems with alcohol or drugs who did not have a medical marijuana card were the most likely to report receiving diverted medical marijuana. Study limitations The generalizability of these findings is limited by collection of data from a single site. The sample may skew to people with lower socioeconomic status because of the hospital’s social mission, but socioeconomic data of respondents were not collected. Details about the legal status of the participants during their hospitalization and the mental illness for which they were treated are not available, though this information would help characterize persons using and diverting medical marijuana. Without complete demographic data, it is impossible to know how this study population compares to the larger sample of medical marijuana registrants in the state, but the available data suggests a concordance with what is known
about that sample. The study sample was clearly a clinical sample rather than a probability sample and does not represent the general population of Colorado. In addition, this study relies on self-report, so it suffers from sampling bias, and thus represents a subset of psychiatric patients who will voluntarily complete an anonymous discharge survey without compensation. Finally, the study instrument did not include psychometric data. In general, our survey was limited by the difficulties of studying the medical use of marijuana. Although permitted in Colorado, the use and possession of marijuana remains a federal crime. Given that we were surveying a vulnerable population, our survey was necessarily limited to preserve the anonymity of our participants. So we did not ask about socioeconomic data or particular diagnoses that could, in combination, compromise a participant’s anonymity. While the resulting survey instrument ably protects the anonymity of participants, it allows for no comparison between participants who did and did not respond to their survey, as well as the intriguing relationships between marijuana use and particular psychiatric disorders like anxiety, depressive, neurocognitive, and psychotic disorders that are associated with marijuana use. Instead, the survey was designed to ask different questions of groups with different exposure to marijuana, but its design appears to have ultimately reduced completion rates. Implications This survey has the largest sample size of any study of medical marijuana use and diversion among persons with mental illness and is the first study to assess the prevalence of use and diversion of medical marijuana among adults admitted to an inpatient psychiatry service. It finds that the use of medical marijuana is much higher than in Colorado’s general population, so the study reminds policy-makers to consider how the legalization of medical marijuana will affect mental health systems. Permitting the medical use of marijuana may benefit a subset of patients, and in further studies, it would be interesting to ask respondents to characterize how marijuana was helpful and how its benefits and tolerability compare to other treatments they receive. For other patients, the legalization of the medical use of marijuana may increase the need for mental health and substance treatment. It would be helpful, in further studies, to characterize these patients so that policy-makers can determine how to spend medical marijuana tax revenue earmarked for mental health and substance treatment. In Colorado, this revenue has exceeded expectations and the recent legalization of the recreational use of marijuana may ultimately create an additional $100 million of tax revenue per year, a portion of which is expected to be spent on substance and mental health treatment (25). At present, policy-makers have targeted prevention efforts and exclusion criteria at adolescents, because the harms of regular marijuana use are most consistently associated with early and persistent use beginning in adolescence (26); this study offers support for such interventions because only 4% of respondents in our study initiated use of marijuana after the age of 25. However, this study suggests the need to better characterize who is harmed and who benefits from increased access to medical marijuana so that public funds can we be well-used.
Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by University of Calgary on 02/02/15 For personal use only.
DOI: 10.3109/00952990.2014.949727
In addition, our study is the first to document diversion of medical marijuana among adults. While our study sample has the limitations described above, it also documents that at least some persons registered to share medical marijuana are sharing or selling their medical marijuana with others. For clinicians interested in knowing if a patient is using medical marijuana, it is insufficient to ask if they registered to use medical marijuana; they should also inquire if someone else shares or sells medical marijuana to them. Researchers should continue to explore the associations between mental illness and cannabis use, as this study demonstrates a higher use of medical marijuana among persons hospitalized with mental illness than in the general population. In future studies, it is critical to better characterize both participants – especially with regards to their patterns of use, socioeconomic status, and particular psychiatric disorders – and the type of marijuana they use. Marijuana is a complex substance and in future studies, it is critical to assess the amount, dose, duration, and strain of marijuana used by participants. In addition, researchers should explore whether or not the advertising of the medical marijuana industry targets people with mental illnesses, as persons with mental illness have been historically targeted by the tobacco industry (27). In doing so, further studies could better characterize when (and how) the medical use of marijuana is harmful and helpful, for persons with mental illnesses.
Acknowledgements We thank Denver Health for encouraging this project and the staff nurses for administering the discharge questionnaire.
Declaration of interest The authors received no funding for this study or the preparation of this paper. Dr Nussbaum receives research support from the University of Chicago and royalties from American Psychiatric Publishing for unrelated projects. Dr Thurstone receives research support from NIDA Grant R01DA201913-04, U10DA013045, U10DA013045-11S3, and R01DA031816-01A1. Ms McGarry and Mr Walker have no relationships to disclose. Dr Sabel receives research support from NIAID, CMMI Health Care Innovation, and High Value Healthcare Collaborative for unrelated projects. The authors alone are responsible for the content and writing of this paper.
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