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.

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.

This thesis is an anthropological exploration of the first legal Canadian Grow Cup (3 years after legalization (October 17, 2018)). It takes a sensory anthropology approach to 'knowing' from practical activity. This approach acknowledges that senses/sensing do not belong to one category, instead, "our sensory perception is inextricable from the cultural categories that we use to give meaning to sensory experiences in social and material interactions" (Pink 2015, 7). Taking this approach aims to address the current legal framework that reduces cannabis to its molecular compounds. The methodological approach is centred around an apprenticeship with an experienced home grower, whom I met online and who agreed to guide me throughout my participation in the grow cup. The organization of the thesis follows my movements through the apprenticeship situated both online and in my mentor's garden in West Ottawa, Ontario. Having to abide by winning criteria based on THC and Terpene metrics, this thesis offers arguments and critique of the current conjoint legal/ public health/ industry framework. The latter framework is in line with mainstream pharmacology, which advocates the need to use purified substances as they are considered more specific and safe. However, I critique this approach of 'knowing' cannabis through the cannabis cup as the "effects" and quality of whole derived cannabis products are quantified and standardized based on a percentage number associated with two out of 100+ molecular compounds. This creates a new phenomenon, shaping cultivation practices focused on single molecule percentage numbers. Therefore, I ask how does a skilled home grower know/sense cannabis, and how does the contest criteria constrain (or not) the home grower's ways of knowing/ sensing cannabis? Answering these questions aims to understand the sensorial ways of knowing cannabis. As such, this thesis does not deal with standardization or metrics directly. Instead, attention is oriented towards what escapes the contest-winning criteria and standardization, my curiosity resting in ways of 'knowing' directly from what is evoked through practical activity.