Pain, Cannabis Species, and Cannabis Use Disorders

An Ecological Examination of Indica Versus Sativa and Primary Terpenes on the Subjective Effects of Smoked Cannabis: A Preliminary Investigation

Background: The legal cannabis landscape has greatly outpaced scientific knowledge. Many popular cannabis claims, such as cultivar (colloquially referred to as strain) classification and terpene content producing different subjective effects, are unsubstantiated. This study examined, for the first time, whether cultivar classification (sativa/indica) and terpene content (caryophyllene, limonene, myrcene, pinene, and terpinolene) were associated with subjective cannabis effects (i.e., pain levels, low-arousal ["indica-like"] effects, high-arousal ["sativa-like"] effects, and negative effects). Methods: Regular cannabis users (n=101) took part in a 2-week long ecological momentary assessment study in which they responded to questions about their cannabis use, stated their preference for sativa versus indica, and reported their in-the-moment subjective effects within 30 min of smoking cannabis. Cultivars were coded for sativa versus indica classification and primary terpene content using Leafly, a popular search engine. Linear mixed-effect models then examined subjective response by sativa/indica and primary terpene. Covariates included demographics (age, sex, race, income), cannabis use (medical use, cannabis use frequency, stated preference for sativa/indica, global expected cannabis effects), morning pain ratings, and specific smoked cannabis occasions (hour of day, minutes since use, context, number of hits, and tetrahydrocannabinol). Results: The majority of participants (78.3%) had a preference for either sativa or indica and reported reasons for their preference that aligned with industry claims. After controlling for covariates, findings revealed that cultivars classified as indica dominant were associated with greater low-arousal (e.g., sluggish, slow) effects relative to the unweighted mean of all cannabis cultivars (b = 0.44, SE=0.16, p=0.01). Cultivars with primary caryophyllene were associated with greater pain ratings (b = 0.53, SE=0.24, p=0.03) and negative effects (b = 0.22, SE=0.08, p=0.01) relative to the mean of all other terpene types. Cultivars with primary pinene were associated with less negative effects (b = -0.35, SE=0.18, p=0.04). Conclusions: Cultivars classified as indica dominant were associated with greater low-arousal effects in models that accounted for both within- and between-person variation, despite the scientific challenges distinguishing between sativa and indica. Preliminary findings also suggest terpenes may play a role in subjective effects. These results emphasize the need for further research, particularly controlled lab studies.

Disentangling Medicinal and Recreational cannabis Use Among People Living with HIV: An Ecological Momentary Assessment Study

This study examined the feasibility of using ecological momentary assessment (EMA) to disentangle medicinal cannabis use (MCU) from recreational cannabis use (RCU) among people living HIV (PLWH). Over a 14-day period, PLWH (N = 29) who engaged in both MCU and RCU completed a smartphone-based survey before and after every cannabis use event assessing general motivation for cannabis use (MCU-only, RCU-only, or mixed MCU/RCU), cannabis use behavior, and several antecedents and outcomes of cannabis use. A total of 739 pre-cannabis surveys were completed; 590 (80%) of the prompted post-cannabis surveys were completed. Motives for cannabis use were reported as MCU-only on 24%, RCU-only on 30%, and mixed MCU/RCU on 46% of pre-cannabis surveys. Mixed effects models examined within-person differences across MCU-only, RCU-only, and mixed MCU/RCU events. Results showed that relative to RCU-only events, MCU-only events were more likely to involve symptom management and drug substitution motives, physical and sleep-related symptoms, solitary cannabis use, and use of cannabis oils and sprays; MCU-only events were less likely to involve relaxation, happiness, and wellness motives, cannabis flower use, and positive cannabis consequences. Differences between mixed MCU/RCU and RCU-only events were similar, except that mixed MCU/RCU events were additionally associated with stress reduction motives and symptoms of anxiety and depression. Findings support the feasibility of partially disentangling MCU and RCU behavior among PLWH who engage in concurrent MCU and RCU. This study highlights the need for more EMA studies isolating MCU from RCU to inform ongoing changes to cannabis policies.

A Scoping Review of Risk and Protective Factors for Negative Cannabis Use Consequences

Objective

Numerous reviews have examined risk and protective factors for alcohol-related negative consequences, but no equivalent review of risk and protective factors exists for cannabis-related negative consequences (CRNCs)-a gap filled by the present study. This scoping review examined survey-based research of risk and protective factors for CRNCs such as neglecting responsibilities, blacking out, or needing more cannabis.

Methods

Three databases (PubMed, PsycINFO, and Google Scholar) were searched for peer-reviewed manuscripts published between January 1, 1990, and December 31, 2021. A qualitative synthesis was performed using the matrix method and the results were organized using the socioecological model as a framework.

Results

Eighty-three studies were included in the review. There was considerable variation in measures and operationalizations of CRNCs across studies. Risk factors were identified in the intrapersonal (depression, social anxiety, PTSD, impulsivity, sensation seeking, motives, expectancies), interpersonal/community (trauma, victimization, family and peer substance use, social norms), and social/policy (education, employment, community attachment, legalization, availability of substances) domains of influence. Protective behavioral strategies were a robust protective factor for CRNCs. Males consistently reported more CRNCs than females, but there were no differences observed across race.

Conclusions

Future research should identify person- and product-specific patterns of CRNCs to refine theoretical models of cannabis misuse and addiction. Public health interventions to reduce the risk of negative consequences from cannabis should consider utilizing multilevel interventions to attenuate the cumulative risk from a combination of psychological, contextual, and social influences.

Use patterns, beliefs, experiences, and behavioral economic demand of indica and sativa cannabis: A cross-sectional survey of cannabis users

Cannabis products available for retail purchase are often marketed based on purported plant species (e.g., "indica" or "sativa"). The cannabis industry frequently claims that indica versus sativa cannabis elicits unique effects and/or is useful for different therapeutic indications. Few studies have evaluated use patterns, beliefs, subjective experiences, and situations in which individuals use indica versus sativa. A convenience sample of cannabis users (n = 179) was surveyed via Amazon Mechanical Turk (mTurk). Participants were asked about their prior use of, subjective experiences with, and opinions on indica versus sativa cannabis and completed hypothetical purchasing tasks for both cannabis subtypes. Participants reported a greater preference to use indica in the evening and sativa in the morning and afternoon. Participants were more likely to perceive feeling "sleepy/tired" or "relaxed" after using indica and "alert," "energized," and "motivated" after using sativa. Respondents were more likely to endorse wanting to use indica if they were going to sleep soon but more likely to use sativa at a party. Hypothetical purchasing patterns (i.e., grams of cannabis purchased as a function of escalating price) did not differ between indica and sativa, suggesting that demand was similar. Taken together, cannabis users retrospectively report feeling different effects from indica and sativa; however, demand generally did not differ between cannabis subtypes, suggesting situational factors could influence whether someone uses indica or sativa. Placebo-controlled, blinded studies are needed to characterize the pharmacodynamics and chemical composition of indica and sativa cannabis and to determine whether user expectancies contribute to differences in perceived indica/sativa effects. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Association of Tetrahydrocannabinol Content and Price in Herbal Cannabis Products Offered by Dispensaries in California: A Purview of Consumers/Patients

Background and Aims

The U.S. legal cannabis market is saturated with products containing high levels of tetrahydrocannabinol (THC), with no distinction between medical and recreational programs. This omnipresence of potent cannabis products seems to be driven by the recreational realm, where cannabis with the highest THC content is prized. This prevalence of highly potent cannabis is conveyed to medical programs, which places consumers (patients) at higher risk for over consumption and cannabis use disorder. Thus, understanding what factors influence the market that patients face in medical cannabis programs could shed light on the risks of legal cannabis. The supply and demand dynamic of the US for-profit cannabis market could explain the current market composition; therefore, we postulate that a financial gain could influence the perpetuation of the prevalence of high THC products in legal cannabis dispensaries. We investigate whether THC content in popular cannabis products correlates with higher prices and assess whether some attributes (type of product, chemovars, or presence of cannabidiol (CBD) affect the association of THC with price.

Methods

We focus on the world's largest cannabis market, California. We randomly selected dispensaries across the state, screened for a web presence and product menu, determined the most prevalent product type, and collected THC and CBD concentration, price, and other product attributes.

Results

We observed that herbal products were more common, they had THC concentrations greater than 10%, and THC concentrations positively correlated with price. This correlation existed in flower and preroll presentations, all chemovar, and independently of the level of CBD. CBD did not correlate with price; however, the presence of CBD diminished the THC and price correlation particularly in products with high THC (>15%).

Conclusions

Overall, highly potent herbal cannabis products (>15% THC) are the majority of products offered and more expensive regardless of product type or chemovar in California dispensaries, suggesting that a financial gain contributes to the current market composition. Efforts to limit the availability of highly potent THC products and educate consumers about potential harms are needed.

Cannabis use as a moderator of cognitive behavioral therapy for insomnia

STUDY OBJECTIVES

Cannabis use is common among young adults and has been proposed as a potential treatment for insomnia. However, controlled studies examining the impact of cannabis use on insomnia symptoms are rare. This secondary analysis of published trial data tested cannabis use during cognitive behavioral treatment for insomnia (CBT-I) as a moderator of treatment efficacy.

METHODS

Young adults (ages 18-30 years) who reported past-month binge drinking (4/5+ drinks for women/men) and met DSM-5 and research diagnostic criteria for Insomnia Disorder were randomized to CBT-I (n=28) or sleep hygiene (SH; n=28). Interaction effects were tested using multilevel models. Outcomes included insomnia severity, actigraphy-assessed sleep efficiency, diary-assessed sleep quality, drinking quantity, and alcohol-related consequences.

RESULTS

Twenty-six participants (46%; 12 SH and 14 CBT-I) reported using cannabis during the treatment phase of the study, on an average of 23% of treatment days (range=3-100%). Relative to those who did not use cannabis, participants who used cannabis during treatment reported heavier drinking and more frequent cigarette use. Approximately 1 in 4 cannabis users (27%) reported using cannabis to help with sleep; however, cannabis and non-cannabis users did not differ in use of alcohol as a sleep aid. Controlling for sex, race, drinking quantity, cigarette use, symptoms of depression, and symptoms of anxiety, use of cannabis during treatment did not moderate CBT-I effects on insomnia severity (b= -.002, p=.99) or other outcomes (all p >.20).

CONCLUSIONS

CBT-I is effective in reducing insomnia symptoms among young adult drinkers with insomnia, regardless of cannabis use.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Identifier: NCT03627832.

A Mapping Literature Review of Medical Cannabis Clinical Outcomes and Quality of Evidence in Approved Conditions in the USA from 2016 to 2019

In 2017, a National Academies of Sciences, Engineering, and Medicine (NASEM) report comprehensively evaluated the body of evidence regarding cannabis health effects through the year 2016. The objectives of this study are to identify and map the most recently (2016-2019) published literature across approved conditions for medical cannabis and to evaluate the quality of identified recent systematic reviews, published following the NASEM report. Following the literature search from 5 databases and consultation with experts, 11 conditions were identified for evidence compilation and evaluation: amyotrophic lateral sclerosis, autism, cancer, chronic noncancer pain, Crohn's disease, epilepsy, glaucoma, human immunodeficiency virus/AIDS, multiple sclerosis (MS), Parkinson's disease, and posttraumatic stress disorder. A total of 198 studies were included after screening for condition-specific relevance and after imposing the following exclusion criteria: preclinical focus, non-English language, abstracts only, editorials/commentary, case studies/series, and non-U.S. study setting. Data extracted from studies included: study design type, outcome definition, intervention definition, sample size, study setting, and reported effect size. Few completed randomized controlled trials (RCTs) were identified. Studies classified as systematic reviews were graded using the Assessing the Methodological Quality of Systematic Reviews-2 tool to evaluate the quality of evidence. Few high-quality systematic reviews were available for most conditions, with the exceptions of MS (9 of 9 graded moderate/high quality; evidence for 2/9 indicating cannabis improved outcomes; evidence for 7/9 indicating cannabis inconclusive), epilepsy (3 of 4 graded moderate/high quality; 3 indicating cannabis improved outcomes; 1 indicating cannabis inconclusive), and chronic noncancer pain (12 of 13 graded moderate/high quality; evidence for 7/13 indicating cannabis improved outcomes; evidence from 6/7 indicating cannabis inconclusive). Among RCTs, we identified few studies of substantial rigor and quality to contribute to the evidence base. However, there are some conditions for which significant evidence suggests that select dosage forms and routes of administration likely have favorable risk-benefit ratios (i.e., epilepsy and chronic noncancer pain). The body of evidence for medical cannabis requires more rigorous evaluation before consideration as a treatment option for many conditions, and evidence necessary to inform policy and treatment guidelines is currently insufficient for many conditions.

A longitudinal examination of daily patterns of cannabis and alcohol co-use among medicinal and recreational veteran cannabis users

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.

Marihuana: legalización y atención médica

Despite the fact that the use of marihuana is illegal in most countries of the world, it still is one of the most commonly used drugs worldwide. 8.6% of the Mexican population, between 12-65 years old, has smoked marihuana at least once in their lifetime (2017). There has been a significant increase in the number of consumers in the last few years. Fatal cases associated with cannabis use had not been recognized for a long time, however, lately, deaths due to a cannabis hyperemesis syndrome (CHS) and deaths from self-mutilation have been reported. Although marihuana synthesizes several active substances with potential therapeutic properties, nowadays, the greatest use of marihuana in our country and in the world is recreational. This review discusses the consequences of using marihuana for recreational use, the social and health contexts regarding legalization and potential therapeutic uses of compounds isolated from the plant based on the scientific literature. Our contribution is to warn people about the potential negative impact on the health of recreational use marihuana and the urgency of supporting the research of its effects on the brain. Similarly, we aim to identify the active principles with potential therapeutic use.

Characterization of mental health in cannabis dispensary users, using structured clinical interviews and standardized assessment instruments

BACKGROUND

Cannabis is commonly used for its medical properties. In particular, cannabis is purported to have beneficial effects on a wide range of neuropsychiatric conditions. Studies assessing mental health in cannabis dispensary users typically evaluate symptoms using self-report check lists, which provide limited information about symptom severity, and whether subjects meet criteria for a psychiatric diagnosis. There is, therefore, a need for studies which assess mental health in dispensary users with standardized and well validated scientific instruments, such as those used in clinical drug trials.

METHODS

One hundred medical cannabis users were recruited from a community dispensary. All subjects completed a structured clinical interview with the Mini-International Neuropsychiatric Interview (MINI). Subjects also completed the Perceived Stress Scale-10, PROMIS Fatigue Scale, PROMIS Sleep Disturbance Scale, Beck Depression Inventory, the Patient Health Questionnaire-15 and the Brief Pain Inventory. Details about cannabis use were also recorded.

RESULTS

Lifetime prevalence of mental illness in this cohort was high, and a large proportion of subjects endorsed psychological symptoms. The proportion of subjects who met criteria for classification of a current psychiatric disorder was low for mood disorders, but high for anxiety disorders and substance abuse/dependence. Cannabis use differed between the main psychiatric conditions.

CONCLUSIONS

The present results indicate that rates of mental illness may be high in medical cannabis dispensary users. Use of structured clinical assessments combined with standardized symptom severity questionnaires provide a feasible way to provide a more rigorous and detailed evaluation of conditions and symptoms in this population.

Associations of PTSD, chronic pain, and their comorbidity on cannabis use disorder: Results from an American nationally representative study

BACKGROUND

Cannabis can be prescribed for posttraumatic stress disorder (PTSD) and chronic pain, and comorbid cannabis use disorder (CUD) can occur in both conditions. Research demonstrates that PTSD and chronic pain commonly co-occur.

METHODS

Data were acquired from the National Epidemiologic Survey on Alcohol and Related Conditions-III (N = 36,309). Past-year CUD and PTSD were assessed using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-5. Past-year physician-confirmed chronic pain was self-reported and classified as musculoskeletal (e.g., arthritis), digestive (e.g., pancreatitis), and nerve (e.g., reflex sympathetic dystrophy) pain. Weighted cross-tabulations assessed sociodemographic, psychiatric, and chronic pain condition variables among those with PTSD versus no PTSD, among the entire sample and among those with CUD and chronic pain. Multiple logistic regressions examined the relationship between PTSD and chronic pain with CUD. CUD characteristics were also evaluated across PTSD and chronic pain groups.

RESULTS

Rates of CUD were elevated in PTSD (9.4%) compared to those without (2.2%). The odds of CUD were greater for PTSD+digestive pain, PTSD+nerve pain, and PTSD+any chronic pain compared to having neither PTSD nor chronic pain (odds ratio range: 1.88-2.32). PTSD with and without comorbid chronic pain was associated with overall elevated rates of adverse CUD characteristics, including earlier age of onset, greater usage, and greater CUD severity.

CONCLUSIONS

PTSD with and without chronic pain is associated with elevated rates and severity of CUD. These results may have implications for prescribing practices and understanding individuals at risk for developing CUD.

Relationships between marijuana use, severity of marijuana-related problems, and health-related quality of life

Studies on the relationships between marijuana use and quality of life have reported mixed findings. Based on a survey of 123 marijuana users conducted in Los Angeles during 2017-2018, we investigated the relationships between marijuana use frequency, severity of marijuana-related problems, and health-related quality of life (HRQoL). Results indicated that (1) marijuana use frequency was positively related to severity of marijuana-related problems; (2) severity of marijuana-related problems was negatively related to mental domain of HRQoL but was not significantly related to physical domain of HRQoL; and (3) marijuana use frequency was positively associated with mental health symptoms and physical health conditions, and both in turn were negatively linked to mental and physical domains of HRQoL, respectively. Reduction of marijuana-related problems and mitigation of mental and physical health problems may improve HRQoL among marijuana users. The study findings may contribute to developing treatment interventions for marijuana use that simultaneously address marijuana-related problems and associated mental and physical issues.

Navigating Blind in the Green Rush: Clinical Considerations and Harm Reduction Practices for Cannabis

Background

The United States has recently experienced extensive changes in state policy regarding the use of cannabis for recreational and medicinal purposes. Despite its rapidly increasing accessibility and social acceptance, there is a striking dearth of research on cannabis as a treatment for medical and psychological conditions. Research on cannabis is difficult to conduct as it is classified as a schedule I drug with high potential for abuse and currently no accepted medical use in treatment. As a result, no standard dosing procedures exist and the lack of conclusive scientific evidence has left clinical providers without evidence-based guidelines about if, when, and how to guide clients on using cannabis safely.

Objective

To (1) provide critical psychoeducational information about cannabis and cannabis problems to guide client-provider conversations about cannabis use and (2) describe common clinical concerns around cannabis use, highlight special considerations for vulnerable populations, and review harm reduction techniques and practical resources that may help clinicians and their clients navigate safer cannabis use.

Conclusion

The removal of regulatory barriers would enable researchers to address key public health questions about the potential therapeutic and adverse effects of cannabis use. Additionally, funds for research, clinician education, and public health education initiatives are necessary to reduce risk around cannabis use in the United States.

The Association between Cannabis Product Characteristics and Symptom Relief

Federal barriers and logistical challenges have hindered measurement of the real time effects from the types of cannabis products used medically by millions of patients in vivo. Between 06/06/2016 and 03/05/2018, 3,341 people completed 19,910 self- administrated cannabis sessions using the mobile device software, ReleafApp to record: type of cannabis product (dried whole natural Cannabis flower, concentrate, edible, tincture, topical), combustion method (joint, pipe, vaporization), Cannabis subspecies (C. indica and C. sativa), and major cannabinoid contents (tetrahydrocannabinol, THC; and cannabidiol, CBD), along with real-time ratings of health symptom severity levels, prior-to and immediately following administration, and reported side effects. A fixed effects panel regression approach was used to model the within-user effects of different product characteristics. Patients showed an average symptom improvement of 3.5 (SD = 2.6) on an 11-point scale across the 27 measured symptom categories. Dried flower was the most commonly used product and generally associated with greater symptom relief than other types of products. Across product characteristics, only higher THC levels were independently associated with greater symptom relief and prevalence of positive and negative side effects. In contrast, CBD potency levels were generally not associated with significant symptom changes or experienced side effects.

Cannabis for Chronic Pain: Challenges and Considerations

The National Academies of Sciences, Engineering, and Medicine has found substantial evidence that cannabis (plant) is effective for the treatment of chronic pain in adults, and moderate evidence that oromucosal cannabinoids (extracts, especially nabiximols) improve short-term sleep disturbances in chronic pain. The paradoxical superiority of the cannabis plant over cannabinoid molecules represents a challenge for the medical community and the established processes that define modern pharmacy. The expanding and variable legalization of cannabis in multiple states nationwide represents an additional challenge for patients and the medical community because recreational and medicinal cannabis are irresponsibly overlapped. Cannabis designed for recreational use (containing high levels of active ingredients) is increasingly available to patients with chronic pain who do not find relief with current pharmacologic entities, which exposes patients to potential harm. This article analyzes the available scientific evidence to address controversial questions that the current state of cannabis poses for health care professionals and chronic pain patients and sets the basis for a more open discussion about the role of cannabis in modern medicine for pain management. A critical discussion on these points, the legal status of cannabis, and considerations for health care providers is presented.

Medicinal versus Recreational Cannabis Use among Returning Veterans

BACKGROUND

Although increasing rates of cannabis use and cannabis use disorder (CUD) are well-documented among veterans, little is known about their use of cannabis specifically for medicinal purposes. The present study characterizes such use and compares veterans reporting cannabis use for medicinal (n = 66) versus recreational (n = 77) purposes on (a) sociodemographic factors, (b) psychiatric disorders (posttraumatic stress disorder [PTSD], major depressive disorder [MDD], and CUD), (c) other substance use, (d) reasons for cannabis use and cannabis-related problems, and (e) physical and mental health.

METHODS

Participants were veterans deployed post 9/11/2001 recruited from a Veterans Health Administration (VHA) facility (N = 143; mean [SD] age = 30.0 [6.6]; mean [SD] deployments = 1.7 [1.1]) who reported past-year cannabis use.

RESULTS

The most frequently endorsed conditions for medicinal cannabis (MC) use were anxiety/stress, PTSD, pain, depression, and insomnia. In logistic regression analyses adjusted for frequency of cannabis use, MC users were significantly more likely (OR = 3.16) to meet criteria for PTSD than recreational cannabis (RC) users. Relative to RC users, MC users reported significantly greater motivation for using cannabis to cope with sleep disturbance as well as significantly poorer sleep quality and worse physical health.

CONCLUSIONS

Veterans who use cannabis for medicinal purposes differ significantly in sleep, physical and mental health functioning than veterans who use cannabis for recreational purposes. PTSD and sleep problems may be especially relevant issues to address in screening and providing clinical care to returning veterans who are using cannabis for medicinal purposes.

Cannabis use patterns and motives: A comparison of younger, middle-aged, and older medical cannabis dispensary patients

INTRODUCTION

Medical cannabis is increasingly being used for a variety of health conditions as more states implement legislation permitting medical use of cannabis. Little is known about medical cannabis use patterns and motives among adults across the lifespan.

METHODS

The present study examined data collected at a medical cannabis dispensary in San Francisco, California. Participants included 217 medical cannabis patients who were grouped into age-defined cohorts (younger: 18-30, middle-aged: 31-50, and older: 51-72). The age groups were compared on several measures of cannabis use, motives and medical conditions using one-way ANOVAs, chi-square tests and linear regression analyses.

RESULTS

All three age groups had similar frequency of cannabis use over the past month; however, the quantity of cannabis used and rates of problematic cannabis use were higher among younger users relative to middle-aged and older adults. The association between age and problematic cannabis use was moderated by age of regular use initiation such that earlier age of regular cannabis use onset was associated with more problematic use in the younger users, but not among older users. Middle-aged adults were more likely to report using medical cannabis for insomnia, while older adults were more likely to use medical cannabis for chronic medical problems such as cancer, glaucoma and HIV/AIDS. Younger participants reported cannabis use when bored at a greater rate than middle-aged and older adults.

CONCLUSIONS

Findings suggest that there is an age-related risk for problematic cannabis use among medical cannabis users, such that younger users should be monitored for cannabis use patterns that may lead to deleterious consequences.

Medical Marijuana: Just the Beginning of a Long, Strange Trip?

Medical marijuana continues to gain acceptance and become legalized in many states. Various species of the marijuana plant have been cultivated, and this plant can contain up to 100 active compounds known as cannabinoids. Two cannabinoids seem the most clinically relevant: Δ9-tetrahydrocannabinol (THC), which tends to produce the psychotropic effects commonly associated with marijuana, and cannabidiol (CBD), which may produce therapeutic effects without appreciable psychoactive properties. Smoking marijuana, or ingesting extracts from the whole plant orally (in baked goods, teas, and so forth), introduces variable amounts of THC, CBD, and other minor cannabinoids into the systemic circulation, where they ultimately reach the central and peripheral nervous systems. Alternatively, products containing THC, CBD, or a combination of both compounds, can be ingested as oral tablets or via sprays applied to the oral mucosal membranes. These products may provide a more predictable method for delivering a known amount of specific cannabinoids into the body. Although there is still a need for randomized controlled trials, preliminary studies have suggested that medical marijuana and related cannabinoids may be beneficial in treating people with chronic pain, inflammation, spasticity, and other conditions seen commonly in physical therapist practice. Physical therapists, therefore, should be aware of the options that are available for patients considering medical marijuana and should be ready to provide information for these patients. Clinicians also should be aware that marijuana can produce untoward effects on cognition, coordination, balance, and cardiovascular and pulmonary function and should be vigilant for any problems that may arise if patients are using cannabinoids during physical rehabilitation.

Identifying HIV care enrollees at-risk for cannabis use disorder

Increased scientific attention given to cannabis in the United States has particular relevance for its domestic HIV care population, given that evidence exists for both cannabis as a therapeutic agent and cannabis use disorder (CUD) as a barrier to antiretroviral medication adherence. It is critical to identify relative risk for CUD among demographic subgroups of HIV patients, as this will inform detection and intervention efforts. A Center For AIDS Research Network of Integrated Clinical Systems cohort (N = 10,652) of HIV-positive adults linked to care at seven United State sites was examined for this purpose. Based on a patient-report instrument with validated diagnostic threshold for CUD, the prevalence of recent cannabis use and corresponding conditional probabilities for CUD were calculated for the aggregate sample and demographic subgroups. Generalized estimating equations then tested models directly examining patient demographic indices as predictors of CUD, while controlling for history and geography. Conditional probability of CUD among cannabis-using patients was 49%, with the highest conditional probabilities among demographic subgroups of young adults and those with non-specified sexual orientation (67-69%) and the lowest conditional probability among females and those 50+ years of age (42% apiece). Similarly, youthful age and male gender emerged as robust multivariate model predictors of CUD. In the context of increasingly lenient policies for use of cannabis as a therapeutic agent for chronic conditions like HIV/AIDS, current study findings offer needed direction in terms of specifying targeted patient groups in HIV care on whom resources for enhanced surveillance and intervention efforts will be most impactful.

Training and Practices of Cannabis Dispensary Staff

Introduction: The proliferation of cannabis dispensaries within the United States has emerged from patient demand for the legalization of cannabis as an alternative treatment for a number of conditions and symptoms. Unfortunately, nothing is known about the practices of dispensary staff with respect to recommendation of cannabis strains/concentrations for specific patient ailments. To address this limitation, the present study assessed the training and practices of cannabis dispensary staff. Materials and Methods: Medical and nonmedical dispensary staff (n=55) were recruited via e-mail and social media to complete an online survey assessing their demographic characteristics, dispensary features, patient characteristics, formal training, and cannabis recommendation practices. Results: Fifty-five percent of dispensary staff reported some formal training for their position, with 20% reporting medical/scientific training. A majority (94%) indicated that they provide specific cannabis advice to patients. In terms of strains, dispensary staff trended toward recommendations of Indica for anxiety, chronic pain, insomnia, nightmares, and Tourette's syndrome. They were more likely to recommend Indica and hybrid plants for post-traumatic stress disorder (PTSD)/trauma and muscle spasms. In contrast, staff were less likely to recommend Indica for depression; hybrid strains were most often recommended for amyotrophic lateral sclerosis (ALS). In terms of cannabinoid concentrations, dispensary staff were most likely to recommend a 1:1 ratio of delta-9-tetrahydrocannabinol (THC):cannabidiol (CBD) for patients suffering from anxiety, Crohn's disease, hepatitis C, and PTSD/trauma, while patients seeking appetite stimulation were most likely to be recommended THC. Staff recommended high CBD for arthritis and Alzheimer's disease and a high CBD or 1:1 ratio for ALS, epilepsy, and muscle spasms. Conclusions: Although many dispensary staff are making recommendations consistent with current evidence, some are recommending cannabis that has either not been shown effective for, or could exacerbate, a patient's condition. Findings underscore the importance of consistent, evidence-based, training of dispensary staff who provide specific recommendations for patient medical conditions.