The legalization of cannabis is increasing across the United States, for both recreational and medical use. This has resulted in a change in public opinion regarding the risks of cannabis use. This is particularly true for the current generation of older adults, which experiences a greater prevalence of cannabis use than previous members of this cohort. Due to decreased perception of risk and medical or emotional issues associated with old age, older adults increasingly use cannabis to cope with their psychiatric and medical symptoms. Current studies provide evidence of an association between using cannabis for medical symptoms and the development of a Cannabis Use Disorder (CUD). However, there is a lack of literature addressing the association between types of symptoms treated with medical marijuana and developing symptoms of CUD. This study developed a survey using the Cannabis Use Disorder Identification Test (CUDIT) and measures for motives and symptoms of cannabis use. This was done to evaluate the presence of CUD symptoms in older adults (ages 55+) who used cannabis in the past six months while owning a Medical Marijuana License (MML). Data preparation included an examination of outliers, multicollinearity, and data distributions. The primary analysis regressed cannabis use pathology onto psychiatric motives and physical motives. The results of this study suggest that those utilizing cannabis for anxiety symptoms experience more symptoms of a cannabis use disorder. At the same time, there was a negative association between using cannabis order for medical symptoms and developing cannabis use disorder symptoms. Additionally, there was no correlation between the amount of cannabis used and its use for physical symptoms.

abstract: Although prior research has identified negative consequences from marijuana use, some states are legalizing marijuana for medical use due to its medical utility. In 2010, the State of Arizona passed medical marijuana legislation, yet, to date, little research has been published about the specific population characteristics of medical marijuana users or their criminal activity. The purpose of this study is to present the characteristics of medical marijuana users and examine the relationship between medical marijuana use and crime, including substance use, by comparing four groups which are medical marijuana users with authorized medical marijuana ID card (authorized medical marijuana users, AuMM users), medical marijuana users without authorized medical marijuana ID card (non-authorized medical marijuana users, NonAuMM users), illegal marijuana users without authorized medical marijuana ID card (non-authorized marijuana users, NonAuM users), and non-marijuana users (Non-users). Data were collected from a sample of recently booked arrestees in Maricopa County, Arizona through the Arizona Arrestee Reporting Information Network (AARIN) project. A total of 2,656 adult arrestees participated in the study. Findings show that authorized medical marijuana users were more likely to be male, younger, and high school graduates. Medical marijuana users, on average, were likely to acquire more marijuana and spend more money on obtaining marijuana compared to non-authorized marijuana users. Whereas the authorized medical marijuana users had a higher probability for DUI and drug selling/making than non-marijuana users, non-authorized medical marijuana users had a higher probability for involvement property crime, violent crime, DUI, and drug selling/making than non-marijuana users. Authorized medical marijuana users were less likely to use meth compared to non-authorized medical marijuana users and non-authorized marijuana users. This study suggests that it is important to recognize the non-authorized medical marijuana users under medical marijuana policy as well as the DUI regulations and medical insurance. / Dissertation/Thesis / Masters Thesis Criminology and Criminal Justice 2014

As legalization of cannabis continues to spread across the United States, many question the public health implications. The term “cannabis” is often used to refer to anything that comes from the plant and can be used recreationally (to get high or alter one’s current state) or medically (to treat a medical condition). While previous research has primarily focused on the impact of recreational cannabis use, few studies have examined cognitive outcomes associated with medical cannabis (MC) use and the potential for development of problematic use in MC patients. Given important distinctions among recreational users and MC patients, it is likely that these distinct populations of cannabis consumers will experience differential cognitive effects and potential for problematic cannabis use. This dissertation is comprised of three studies. The first is a cross-sectional study that explores executive function and verbal learning and memory in recreational cannabis users relative to healthy controls who do not use cannabis, while also assessing whether cannabis use patterns (e.g., age of onset, urinary THC levels) influence findings. The second study is an observational, longitudinal study which examines executive function and memory, as well as changes in mood, anxiety, sleep, and quality of life in MC patients over 12 months of MC treatment relative to pre-MC treatment. In the third study, symptoms and behaviors associated with problematic cannabis use are examined in cohorts from study 1 and study 2. Specifically, scores on the Cannabis Use Disorder Identification Test – Revised (CUDIT-R) are assessed in MC patients over the course of treatment and also compared to a previously recruited cohort of recreational cannabis users; the validity of the CUDIT-R is also explored. Despite previous research, in the current study recreational users did not exhibit cognitive decrements relative to healthy controls. In MC patents, cognitive performance was stable over the course of 12 months of MC treatment relative to pre-MC treatment performance, and overall they reported improved ratings of mood, anxiety, sleep, and some aspects of quality of life. Although the CUDIT-R suggests MC patients’ average scores do not meet the threshold for possible cannabis use disorder, analyses revealed this measure is not valid and therefore not appropriate in MC patients. Although changes in cognition were not detected in recreational users or MC patients in the current studies, a number of methodological limitations (e.g., sample size and limited ability to adjust for confounding variables) must be considered as these factors likely affected study results. Future studies evaluating the impact of cannabis use will benefit from carefully considering the definition of cannabis itself, goal of use, product choice, and age of onset of use. Researchers and clinicians will also benefit from the development of screening tools specifically designed to assess cannabis use disorder in those who use cannabis for medical purposes.

Marijuana is the most frequently used illegal substance in the United States and is most widely used among young people aged 12 to 21 years. Accurate screening and monitored issuance of medical cannabis recommendations have been shown to decrease abuse rates of the substance, create fewer deaths from opiates, reduce crime rates, reduce marijuana use in youths, decrease car crash deaths, and lessen prevalence of suicide in young men. The purpose of this project was to explore whether multiple screening methods for depression and anxiety in patients who seek medical cannabis referrals for anxiety and depression would improve screening and cannabis referral accuracy. A comprehensive review of the literature was conducted, and 2 screening tools were identified. The tools identified were the Zung self-rating anxiety scale and the Diagnostic and Statistical Manual of Mental Disorders 5 scale. The medical director at the project site reviewed the tools and approved them. These tools were then included in an education program for 12 staff members and providers with a pretest given to the participants prior to the staff education program. A posttest was then administered to the same group after the staff education program was completed and the new screening measures implemented. Results showed that referrals for cannabis were at 85% before the 2-step screening process was implemented; referrals for cannabis decreased to 60% with implementation of the dual screening method, suggesting increased accuracy in screening for depression and anxiety for cannabis referrals. This project might promote positive social change by increasing accuracy for cannabis referrals and reducing the risk of cannabis abuse.

Therapeutic benefits of medicinal cannabis are well documented in the treatment of a variety of medical conditions. There is not, however, a nationally consistent delivery system, which has prevented many patients from realizing these benefits. Using policy feedback theory as the foundation, the purpose of this general qualitative study was to better understand how state-level regulatory efforts in medicinal cannabis may provide guidance on formulating national public policies that are beneficial to patients. This study compared 3 core tenets of NORML, an authority in the cannabis industry, against the policies of 3 states with exemplary state medical cannabis programs. The tenets included access to whole-plant cannabis, wide latitude for doctors to decide treatment regimens, and the right to cultivation for personal use. Data collected from publicly available documents such as legislative archives, state government websites, cannabis coalition groups, and media coverage of medicinal cannabis legislation were deductively coded and subjected to a cross-case analysis procedure. Findings indicated a lack of full alignment with NORML's core tenets as well as significant gaps between research on the efficacy of medical cannabis and the regulatory systems governing delivery within the states. Future policy makers may consider these results in devising nationwide legislation to research and recognize the medicinal use of cannabis, thus addressing the identified need for a uniform delivery system in the US for patients in need of cannabis for medical purposes. This study may contribute to positive social change through recommendations to federal legislators for creating a national government model for patient access to medicinal cannabis.

The thesis is comprised of three separate studies that each relate to one of the aforementioned therapy types: complementary, alternative, and integrative medicine (CAIM), natural health products (NHPs), and medical cannabis. Parallels can be drawn across these therapy types in general including patient preference and prevalence of use, quality of patient health information, and safety and effectiveness concerns. Knowledge of these parallels both informed the development of these three studies and emerged across findings. Chapter 1 provides a comprehensive introduction to these parallels in the context of CAIM, NHPs, and medical cannabis. Chapter 2 comprises a cross-sectional survey determining NHP use disclosure to primary care physicians among patients attending a Canadian naturopathic clinic. Chapter 3 comprises a qualitative interview study identifying attitudes towards medical cannabis among family physicians practicing in Ontario, Canada. Chapter 4 comprises a sentiment analysis of Twitter data to understand how CAIM is mentioned during the COVID-19 pandemic. Lastly, chapter 5 serves as the conclusion of this thesis, and summarizes the most important findings, addresses study strengths and limitations, and discusses future directions from this work. / Thesis / Doctor of Philosophy (PhD)

Indiana University-Purdue University Indianapolis (IUPUI) / Policy and natural shocks are exogenous factors, which may disrupt patients’ ability to access recommended health care. My dissertation investigates the effect of recent natural and policy shocks in health care provision on different patient outcomes. The first chapter studies the effect of the 2014 Ebola virus epidemic in West Africa on maternal health care utilization and infant health in Sierra Leone. The Epidemic resulted in the diversion of the limited health care resource away from other services to care for Ebola patients. It also led to maternal stress from fear of infection and community breakdown. The results show the outbreak led to significant decline in maternal health care utilization and infant birth weight. The second chapter examines whether physician practices that are vertically integrated with hospitals provide healthcare at higher costs than non-integrated practices in a Medicare patient population. The degree of integration is exogenously assigned to a patient following a geographical move. The study finds that switching to integrated practice increases health care utilization and spending. Although integration may increase quality of care, the increase in spending suggests the need for a continuing attention to policies and incentives that are associated with integration. Finally, the third chapter documents the impact of the recent changes in state medical and recreational cannabis access laws in the United States on health care utilization. The liberalization of access to cannabis may enable patients to substitute cannabis for another prescription and non-prescription health care services. The results show a significant decline in the utilization of emergency and outpatient services among patients with chronic pain for the states that legalized cannabis. The effect is mainly due to medical cannabis laws, whereas the effect of recreational cannabis is ambiguous. The three chapters, taken together, show that exogenous shocks, such as natural shocks and government policy, affect health care utilization and the health of individuals. Health policies should, therefore, target developing a resilient health care system that withstands natural shocks and promote policies that provide better treatment alternatives.

The purpose of this integrative literature review was to understand the effects of medical cannabis for chronic pain management in adults. Anecdotal reports suggest the use of medical marijuana as a pain management therapy could be an alternative to opioids and other medications which have long term consequences. Potential uses span the health care continuum, from prescribed outpatient symptom management, to acute care, extended care, home care, and hospice treatment settings. The methodology included a review and synthesis of relevant research articles from 2012 to 2018, written in the English language. The findings suggest medical cannabis has the potential of effectively managing chronic pain in older adults. Adverse effects, if present, are mild and resolve without intervention. Lower doses of medical cannabis were reported to be more effective in treating chronic pain compared to higher doses. Inconsistencies in the efficacy of THC were noted compared to CBD for managing neuropathic pain. Implication for nursing practice, policy, education, and recommendation for future research were discussed along with study limitations.

Kronisk smärta är ett utbrett problem och konventionell farmakologisk smärtbehandling upplevs otillräcklig av många patienter. Medicinsk cannabis (MC) diskuteras idag som ett smärtlindringsalternativ, men mer forskning rekommenderas inom området för att fastställa riskerna förenade med kort- och långtidsbehandling. Syftet med litteraturstudien var att undersöka patienters upplevelse av MC som smärtlindrande behandling vid kronisk smärta. En induktiv ansats valdes, varav tre artiklar med kvalitativ ansats, sju artiklar med kvantitativ ansats samt en mixad-metod artikel, inkluderades i resultatet. En analys av materialet genomfördes och teman med tillhörande subteman utformades. I resultatet redovisas olika aspekter, som påverkar upplevelsen av behandling med MC. Stigmatisering kring MC upplevdes förekomma från både omgivning och hälso- och sjukvårdspersonal. Reducerad smärtpåverkan, upplevd ökad livskvalitet och reducering av andra läkemedel var andra aspekter som redovisades, men även oönskade effekter av läkemedlet visade sig förekomma. Litteraturstudien visar att sjuksköterskor bör erhålla kunskap om läkemedlet, samt upplevelsen av det, för att kunna bemöta och informera patienter som efterfrågar denna behandling mot kronisk smärta. Sjuksköterskor behöver samtidigt vara medvetna om risker förenade med läkemedlet och arbeta proaktivt för att undvika att det hanteras fel och missbrukas. / Chronic pain is a widespread issue and conventional analgesic treatment is insufficient for many patients. Medical cannabis (MC) is discussed today as a pain management alternative but more research is recommended in the field to determine the risks associated with short-term and long-term treatment. The aim of this literature-based study was to explore patient´s experiences of MC as an analgesic treatment in chronic pain. An inductive approach was chosen, of which three articles with a qualitative approach, seven articles with a quantitative approach and a mixed-method article were included in the result. An analysis of the content was conducted and themes with associated subthemes were designed. The result presents different aspects that affect the experience of MC as a treatment. Stigmatization related to MC was found to occur from both the surrounding sphere and healthcare staff. Reduced pain-intensity, increased quality of life and reduction of other drugs were reported. The literature study shows that nurses should acquire knowledge about the drug as well as the experience of it, in order to respond to and inform patients who request this treatment for chronic pain. Nurses also need to be aware of the potential risks of the drug with, for example, adverse effects and risk of further abuse, and work proactively to avoid this.

Background: While recreational cannabis use is common, medical cannabis programs have proliferated across North America, including a federal program in Canada. Few comparisons of medical and recreational cannabis users (RCUs) exist; this study compared these groups on key characteristics. Methods: Data came from a community-recruited sample of formally approved medical cannabis users (MCUs; n = 53), and a sub-sample of recreational cannabis users (RCUs; n = 169) from a representative adult survey in Ontario (Canada). Samples were telephone-surveyed on identical measures, including select socio-demographic, substance and medication use, and health and disability measures. Based on initial bivariate comparisons, multivariate logistical regression with a progressive adjustment approach was performed to assess independent predictors of group status. Results: In bivariate analyses, older age, lower household income, lower alcohol use, higher cocaine, prescription opioid, depression and anxiety medication use, and lower health and disability status were significantly associated with medical cannabis use. In the multivariate analysis, final model, household income, alcohol use, and disability levels were associated with medical cannabis use. Conclusions/Scientific Significance: Compared to RCUs, medical users appear to be mainly characterized by factors negatively influencing their overall health status. Future studies should investigate the actual impact and net benefits of medical cannabis use on these health problems.