Aaron L. Sarvet

US Adult Illicit Cannabis Use, Cannabis Use Disorder, and Medical Marijuana Laws: 1991-1992 to 2012-2013

Importance Over the last 25 years, illicit cannabis use and cannabis use disorders have increased among US adults, and 28 states have passed medical marijuana laws (MML). Little is known about MML and adult illicit cannabis use or cannabis use disorders considered over time. Objective To present national data on state MML and degree of change in the prevalence of cannabis use and disorders. Design, Participants, and Setting Differences in the degree of change between those living in MML states and other states were examined using 3 cross-sectional US adult surveys: the National Longitudinal Alcohol Epidemiologic Survey (NLAES; 1991-1992), the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC; 2001-2002), and the National Epidemiologic Survey on Alcohol and Related Conditions–III (NESARC-III; 2012-2013). Early-MML states passed MML between NLAES and NESARC (“earlier period”). Late-MML states passed MML between NESARC and NESARC-III (“later period”). Main Outcomes and Measures Past-year illicit cannabis use and DSM-IV cannabis use disorder. Results Overall, from 1991-1992 to 2012-2013, illicit cannabis use increased significantly more in states that passed MML than in other states (1.4–percentage point more; SE, 0.5; P = .004), as did cannabis use disorders (0.7–percentage point more; SE, 0.3; P = .03). In the earlier period, illicit cannabis use and disorders decreased similarly in non-MML states and in California (where prevalence was much higher to start with). In contrast, in remaining early-MML states, the prevalence of use and disorders increased. Remaining early-MML and non-MML states differed significantly for use (by 2.5 percentage points; SE, 0.9; P = .004) and disorder (1.1 percentage points; SE, 0.5; P = .02). In the later period, illicit use increased by the following percentage points: never-MML states, 3.5 (SE, 0.5); California, 5.3 (SE, 1.0); Colorado, 7.0 (SE, 1.6); other early-MML states, 2.6 (SE, 0.9); and late-MML states, 5.1 (SE, 0.8). Compared with never-MML states, increases in use were significantly greater in late-MML states (1.6–percentage point more; SE, 0.6; P = .01), California (1.8–percentage point more; SE, 0.9; P = .04), and Colorado (3.5–percentage point more; SE, 1.5; P = .03). Increases in cannabis use disorder, which was less prevalent, were smaller but followed similar patterns descriptively, with change greater than never-MML states in California (1.0–percentage point more; SE, 0.5; P = .06) and Colorado (1.6–percentage point more; SE, 0.8; P = .04). Conclusions and Relevance Medical marijuana laws appear to have contributed to increased prevalence of illicit cannabis use and cannabis use disorders. State-specific policy changes may also have played a role. While medical marijuana may help some, cannabis-related health consequences associated with changes in state marijuana laws should receive consideration by health care professionals and the public.

Association of State Recreational Marijuana Laws With Adolescent Marijuana Use.

Importance Historical shifts are occurring in marijuana policy. The effect of legalizing marijuana for recreational use on rates of adolescent marijuana use is a topic of considerable debate. Objective To examine the association between the legalization of recreational marijuana use in Washington and Colorado in 2012 and the subsequent perceived harmfulness and use of marijuana by adolescents. Design, Setting, and Participants We used data of 253 902 students in eighth, 10th, and 12th grades from 2010 to 2015 from Monitoring the Future, a national, annual, cross-sectional survey of students in secondary schools in the contiguous United States. Difference-in-difference estimates compared changes in perceived harmfulness of marijuana use and in past-month marijuana use in Washington and Colorado prior to recreational marijuana legalization (2010-2012) with postlegalization (2013-2015) vs the contemporaneous trends in other states that did not legalize recreational marijuana use in this period. Main Outcomes and Measures Perceived harmfulness of marijuana use (great or moderate risk to health from smoking marijuana occasionally) and marijuana use (past 30 days). Results Of the 253 902 participants, 120 590 of 245 065(49.2%) were male, and the mean (SD) age was 15.6 (1.7) years. In Washington, perceived harmfulness declined 14.2% and 16.1% among eighth and 10th graders, respectively, while marijuana use increased 2.0% and 4.1% from 2010-2012 to 2013-2015. In contrast, among states that did not legalize recreational marijuana use, perceived harmfulness decreased by 4.9% and 7.2% among eighth and 10th graders, respectively, and marijuana use decreased by 1.3% and 0.9% over the same period. Difference-in-difference estimates comparing Washington vs states that did not legalize recreational drug use indicated that these differences were significant for perceived harmfulness (eighth graders: % [SD], −9.3 [3.5]; P = .01; 10th graders: % [SD], −9.0 [3.8]; P = .02) and marijuana use (eighth graders: % [SD], 5.0 [1.9]; P = .03; 10th graders: % [SD], 3.2 [1.5]; P = .007). No significant differences were found in perceived harmfulness or marijuana use among 12th graders in Washington or for any of the 3 grades in Colorado. Conclusions and Relevance Among eighth and 10th graders in Washington, perceived harmfulness of marijuana use decreased and marijuana use increased following legalization of recreational marijuana use. In contrast, Colorado did not exhibit any differential change in perceived harmfulness or past-month adolescent marijuana use following legalization. A cautious interpretation of the findings suggests investment in evidence-based adolescent substance use prevention programs in any additional states that may legalize recreational marijuana use.

Trends in Marijuana Use Among Pregnant and Nonpregnant Reproductive-Aged Women, 2002-2014.

Between 2001 and 2013, marijuana use among US adults more than doubled, many states legalized marijuana use, and attitudes toward marijuana became more permissive.1 In aggregated 2007–2012 data, 3.9% of pregnant women and 7.6% of non-pregnant reproductive-aged women reported past-month marijuana use.2 Although the evidence is mixed, human and animal studies suggest that prenatal marijuana exposure may be associated with poor offspring outcomes (e.g., low birthweight; impaired neurodevelopment).3 The American College of Obstetricians and Gynecologists recommends that pregnant women and women contemplating pregnancy be screened for and discouraged from using marijuana and other substances.4 Whether marijuana use has changed over time among pregnant and non-pregnant reproductive-aged women is unknown.

Changes in US Lifetime Heroin Use and Heroin Use Disorder: Prevalence From the 2001-2002 to 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions

Importance Heroin use is an urgent concern in the United States. Little is know about the course of heroin use, heroin use disorder, and associated factors. Objective To examine changes in the lifetime prevalence, patterns, and associated demographics of heroin use and use disorder from 2001-2002 to 2012-2013 in 2 nationally representative samples of the US adult general population. Design, Setting, and Participants This survey study included data from 43 093 respondents of the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) and 36 309 respondents of the 2012-2013 NESARC-III. Data were analyzed from February 2 to September 15, 2016. Main Outcomes and Measures Lifetime heroin use and DSM-IV heroin use disorder. Results Among the 79 402 respondents (43.3% men; 56.7% women; mean [SD] age, 46.1 [17.9] years), prevalence of heroin use and heroin use disorder significantly increased from 2001-2002 to 2012-2013 (use: 0.33% [SE, 0.03%] vs 1.6% [SE, 0.08%]; disorder: 0.21% [SE, 0.03%] vs 0.69% [SE, 0.06%]; P < .001). The increase in the prevalence of heroin use was significantly pronounced among white (0.34% [SE, 0.04%] in 2001-2002 vs 1.90% [SE, 0.12%] in 2012-2013) compared with nonwhite (0.32% [SE, 0.05%] in 2001-2002 vs 1.05% [SE, 0.10%] in 2012-2013; P < .001) individuals. The increase in the prevalence of heroin use disorder was more pronounced among white individuals (0.19% [SE, 0.03%] in 2001-2002 vs 0.82% [SE, 0.08%] in 2012-2013; P < .001) and those aged 18 to 29 (0.21% [SE, 0.06%] in 2001-2002 vs 1.0% [0.17%] in 2012-2013; P = .01) and 30 to 44 (0.20% [SE, 0.04%] in 2001-2002 vs 0.77% [0.10%] in 2012-2013; P = .03) years than among nonwhite individuals (0.25% [SE, 0.04%] in 2001-2002 vs 0.43% [0.07%] in 2012-2013) and older adults (0.22% [SE, 0.04%] in 2001-2002 vs 0.51% [SE, 0.07%] in 2012-2013). Among users, significant differences were found across time in the proportion of respondents meeting DSM-IV heroin use disorder criteria (63.35% [SE, 4.79%] in 2001-2001 vs 42.69% [SE, 2.87%] in 2012-2013; P < .001). DSM-IV heroin abuse was significantly more prevalent among users in 2001-2002 (37.02% [SE, 4.67%]) than in 2012-2013 (19.19% [SE, 2.34%]; P = .001). DSM-IV heroin dependence among users was similar in 2001-2002 (28.22% [SE, 3.95%]) and in 2012-2013 (25.02% [SE, 2.20%]; P = .48). The proportion of those reporting initiation of nonmedical use of prescription opioids before initiating heroin use increased across time among white individuals (35.83% [SE, 6.03%] in 2001-2002 to 52.83% [SE, 2.88%] in 2012-2013; P = .01). Conclusions and Relevance The prevalence of heroin use and heroin use disorder increased significantly, with greater increases among white individuals. The nonmedical use of prescription opioids preceding heroin use increased among white individuals, supporting a link between the prescription opioid epidemic and heroin use in this population. Findings highlight the need for educational campaigns regarding harms related to heroin use and the need to expand access to treatment in populations at increased risk for heroin use and heroin use disorder.

The widening gender gap in marijuana use prevalence in the U.S. during a period of economic change, 2002-2014.

AIM Concurrently with increasingly permissive attitudes towards marijuana use and its legalization, the prevalence of marijuana use has increased in recent years in the U.S. Substance use is generally more prevalent in men than women, although for alcohol, the gender gap is narrowing. However, information is lacking on whether time trends in marijuana use differ by gender, or whether socioeconomic status in the context of the Great Recession may affect these changes. METHODS Using repeated cross-sectional data from the National Survey on Drug Use and Health (2002-2014), we examined changes over time in prevalence of past-year marijuana use by gender, and whether gender differences varied across income levels. After empirically determining a change point in use in 2007, we used logistic regression to test interaction terms including time, gender, and income level. RESULTS Prevalence of marijuana use increased for both men (+4.0%) and women (+2.7%) from 2002 to 2014, with all of the increase occurring from 2007 to 2014. Increases were greater for men, leading to a widening of the gender gap over time (p<0.001). This divergence occurred primarily due to increased prevalence among men in the lowest income level (+6.2%) from 2007 to 2014. CONCLUSION Our findings are consistent with other studies documenting increased substance use during times of economic insecurity, especially among men. Corresponding with the Great Recession and lower employment rate beginning in 2007, low-income men showed the greatest increases in marijuana use during this period, leading to a widening of the gender gap in prevalence of marijuana use over time.

Cannabis use, attitudes, and legal status in the U.S.: A review

Cannabis is widely used among adolescents and adults. In the U.S., marijuana laws have been changing, and Americans increasingly favor legalizing cannabis for medical and recreational uses. While some can use cannabis without harm, others experience adverse consequences. The objective of this review is to summarize information on the legal status of cannabis, perceptions regarding cannabis, prevalence and time trends in use and related adverse consequences, and evidence on the relationship of state medical (MML) and recreational (RML) marijuana laws to use and attitudes. Twenty-nine states now have MMLs, and eight of these have RMLs. Since the early 2000s, adult and adolescent perception of cannabis use as risky has decreased. Over the same time, the prevalence of adolescent cannabis use has changed little. However, adult cannabis use, disorders, and related consequences have increased. Multiple nationally representative studies indicate that MMLs have had little effect on cannabis use among adolescents. However, while MML effects have been less studied in adults, available evidence suggests that MMLs increase use and cannabis use disorders in adults. While data are not yet available to evaluate the effect of RMLs, they are likely to lower price, increase availability, and thereby increase cannabis use. More permissive marijuana laws may accomplish social justice aims (e.g., reduce racial disparities in law enforcement) and generate tax revenues. However, such laws may increase cannabis-related adverse health and psychosocial consequences by increasing the population of users. Dissemination of balanced information about the potential health harms of cannabis use is needed.

Epidemiology of Adult DSM-5 Major Depressive Disorder and Its Specifiers in the United States

Importance No US national data are available on the prevalence and correlates of DSM-5–defined major depressive disorder (MDD) or on MDD specifiers as defined in DSM-5. Objective To present current nationally representative findings on the prevalence, correlates, psychiatric comorbidity, functioning, and treatment of DSM-5 MDD and initial information on the prevalence, severity, and treatment of DSM-5 MDD severity, anxious/distressed specifier, and mixed-features specifier, as well as cases that would have been characterized as bereavement in DSM-IV. Design, Setting, and Participants In-person interviews with a representative sample of US noninstitutionalized civilian adults (≥18 years) (n = 36 309) who participated in the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions III (NESARC-III). Data were collected from April 2012 to June 2013 and were analyzed in 2016-2017. Main Outcomes and Measures Prevalence of DSM-5 MDD and the DSM-5 specifiers. Odds ratios (ORs), adjusted ORs (aORs), and 95% CIs indicated associations with demographic characteristics and other psychiatric disorders. Results Of the 36 309 adult participants in NESARC-III, 12-month and lifetime prevalences of MDD were 10.4% and 20.6%, respectively. Odds of 12-month MDD were significantly lower in men (OR, 0.5; 95% CI, 0.46-0.55) and in African American (OR, 0.6; 95% CI, 0.54-0.68), Asian/Pacific Islander (OR, 0.6; 95% CI, 0.45-0.67), and Hispanic (OR, 0.7; 95% CI, 0.62-0.78) adults than in white adults and were higher in younger adults (age range, 18-29 years; OR, 3.0; 95% CI, 2.48-3.55) and those with low incomes (

Sexual assault incidents among college undergraduates: Prevalence and factors associated with risk

19 999 or less; OR, 1.7; 95% CI, 1.49-2.04). Associations of MDD with psychiatric disorders ranged from an aOR of 2.1 (95% CI, 1.84-2.35) for specific phobia to an aOR of 5.7 (95% CI, 4.98-6.50) for generalized anxiety disorder. Associations of MDD with substance use disorders ranged from an aOR of 1.8 (95% CI, 1.63-2.01) for alcohol to an aOR of 3.0 (95% CI, 2.57-3.55) for any drug. Most lifetime MDD cases were moderate (39.7%) or severe (49.5%). Almost 70% with lifetime MDD had some type of treatment. Functioning among those with severe MDD was approximately 1 SD below the national mean. Among 12.9% of those with lifetime MDD, all episodes occurred just after the death of someone close and lasted less than 2 months. The anxious/distressed specifier characterized 74.6% of MDD cases, and the mixed-features specifier characterized 15.5%. Controlling for severity, both specifiers were associated with early onset, poor course and functioning, and suicidality. Conclusions and Relevance Among US adults, DSM-5 MDD is highly prevalent, comorbid, and disabling. While most cases received some treatment, a substantial minority did not. Much remains to be learned about the DSM-5 MDD specifiers in the general population.

Association Between Prescription Drug Monitoring Programs and Nonfatal and Fatal Drug Overdoses: A Systematic Review

Sexual assault on college campuses is a public health issue. However varying research methodologies (e.g., different sexual assault definitions, measures, assessment timeframes) and low response rates hamper efforts to define the scope of the problem. To illuminate the complexity of campus sexual assault, we collected survey data from a large population-based random sample of undergraduate students from Columbia University and Barnard College in New York City, using evidence based methods to maximize response rates and sample representativeness, and behaviorally specific measures of sexual assault to accurately capture victimization rates. This paper focuses on student experiences of different types of sexual assault victimization, as well as sociodemographic, social, and risk environment correlates. Descriptive statistics, chi-square tests, and logistic regression were used to estimate prevalences and test associations. Since college entry, 22% of students reported experiencing at least one incident of sexual assault (defined as sexualized touching, attempted penetration [oral, anal, vaginal, other], or completed penetration). Women and gender nonconforming students reported the highest rates (28% and 38%, respectively), although men also reported sexual assault (12.5%). Across types of assault and gender groups, incapacitation due to alcohol and drug use and/or other factors was the perpetration method reported most frequently (> 50%); physical force (particularly for completed penetration in women) and verbal coercion were also commonly reported. Factors associated with increased risk for sexual assault included non-heterosexual identity, difficulty paying for basic necessities, fraternity/sorority membership, participation in more casual sexual encounters (“hook ups”) vs. exclusive/monogamous or no sexual relationships, binge drinking, and experiencing sexual assault before college. High rates of re-victimization during college were reported across gender groups. Our study is consistent with prevalence findings previously reported. Variation in types of assault and methods of perpetration experienced across gender groups highlight the need to develop prevention strategies tailored to specific risk groups.

Medical marijuana laws and adolescent marijuana use in the United States: a systematic review and meta-analysis

The overuse of prescription opioids during the past 2 decades has evolved into a major public health issue in the United States. Opioid prescribing increased 350% between 1999 and 2015, from 180 to 640 morphine milligram equivalents per capita (1), with parallel increases in nonmedical use (2, 3), neonatal abstinence syndrome (4), and deaths due to both prescription opioid and heroin overdose (5, 6). The age-adjusted rate of prescription opioidrelated deaths rose from 1.0 to 4.4 deaths per 100000 population between 1999 and 2016, whereas heroin-related deaths increased nearly 5-fold since 2010, rising from 1.0 to 4.9 deaths per 100000 population between 2010 and 2016 (7). State prescription drug monitoring programs (PDMPs) have been advanced as a critical tool to better inform clinical care, identify illegal prescribing, and reduce prescription opioidrelated morbidity and mortality (8, 9). By 2017, all 50 states and the District of Columbia had an operational PDMP or passed legislation to operate a PDMP. Although PDMPs in the United States have commonalities in terms of centralized statewide data systems that electronically transmit prescription data, the administrative features of PDMPs have varied substantially among states and over time. Programs operate under different regulatory agencies, collect different types of data, require data to be updated at different intervals, and allow access to different groups of people. Despite this variability in PDMP administrative features, previous studies found implementation of these programs to be associated with reductions in the supply (10), diversion (11), and misuse of prescription opioids (12). As such, PDMPs are increasingly promoted as valuable, user-friendly, accurate, and real-time digital resources for providers and law enforcement alike (13, 14). However, evidence for the effect of PDMPs on drug-induced overdoses remains unclear. The objective of our review was to systematically search and review the literature to assess whether PDMPs are associated with changes in nonfatal or fatal overdoses; to evaluate whether specific administrative features of PDMPs are differentially associated with these outcomes and, if so, which features are most influential; and to investigate any potential unintended consequences associated with PDMPs. Methods Data Sources and Searches We followed a predefined protocol developed in November 2016 (Supplement 1 and structured reporting of the review according to PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines (15). We searched 5 online databases (MEDLINE, Current Contents Connect [Clarivate Analytics], Science Citation Index [Clarivate Analytics], Social Sciences Citation Index [Clarivate Analytics], and ProQuest Dissertations) for titles and abstracts of articles that examined an association between PDMP implementation and nonfatal or fatal drug overdoses. We did not impose a time or language restriction on searches (that is, queries surveyed the entire history of each online database). We included dissertations and peer-reviewed articles, as well as both published and in-process texts. We also examined references from the selected materials to identify additional articles and searched ClinicalTrials.gov. The search was first conducted in November 2016 and repeated in December 2017. All the resulting study titles and abstracts were exported to Covidence, a Web interface developed by Cochrane to systematize the review process (16). For the search terms and algorithm used in the literature search, see Appendix Table 1. Supplement. Supplementary Material Appendix Table 1. Search Strategy Study Selection All titles and abstracts were independently screened by 1 of 3 investigators (D.S.F., J.P.S., or K.K.G.) for eligibility, and those considered relevant by any investigator advanced to the full-text review. We included observational studies published in English if they estimated the before-and-after change in rates of nonfatal or fatal drug overdoses after a PDMP was implemented within a single U.S. state or in a set of states. No restrictions were placed on sample size or population age. A PDMP was considered implemented when a state operationalized its program and began to collect and distribute data or to make the data available to authorized users. Data Extraction and Quality Assessment Two researchers (J.P.S. and K.K.G.) independently read selected articles. Using a standardized article assessment form, they captured data on the specific policy studied; outcome data sources; study design; and results, including point estimates and CIs or P values. After the data were abstracted independently from each study, the 2 researchers reviewed the data for each article to ensure consistency and resolve differences. Disagreements between the researchers were reconciled by the first author (D.S.F.). Finally, 2 investigators independently assessed risk of bias (ROB) for the overdose outcomes reported in each study by using the Cochrane Risk Of Bias In Non-randomized Studiesof Interventions (ROBINS-I) assessment tool (17). By answering questions provided by ROBINS-I, the investigators assessed ROB within 8 specific bias domains (confounding, selection of participants, classification, deviations from intended interventions, missing data, measurement of outcomes, selection of the reported results, and overall bias), grading each domain as low, moderate, serious, or critical. Disagreements were resolved by consensus. Data Synthesis and Analysis Because of substantial heterogeneity in the policies examined and the analytic methods applied, we did not do a meta-analysis. Instead, we performed a qualitative assessment and synthesis using methods outlined by the Agency for Healthcare Research and Quality (18). We categorized studies into 5 groups: PDMP implementation only, specific administrative features only, both PDMP implementation and specific administrative features, PDMP implementation with other opioid policies, and PDMP robustness. Studies examining only PDMP implementation treated all PDMPs as homogenous programs without considering how their administrative features have varied among states and over time. Studies investigating specific administrative features compared states with a PDMP having a specific feature (such as mandatory registration or use, frequency of reporting, or proactive reporting) with states that either had no PDMP or had a PDMP without the specific feature. Studies of PDMPs implemented with other, associated opioid policies examined the contribution of PDMP features to those policies. Finally, studies examining PDMP robustness presented quantitative ratings of PDMP features according to their potential effectiveness in reducing diversion and overdose. We also examined 3 outcomes: nonfatal overdoses, fatal overdoses, and unintended consequences. The investigators assessed the overall strength of evidence (SOE), considering 5 domains: study limitations (determined by using ROBINS-I), directness (whether evidence linked interventions directly to a key question in the review), consistency (degree to which studies found the same direction of effect estimates), precision (degree of certainty surrounding an effect estimate), and reporting bias (selective publishing or reporting of findings on the basis of favorability of the direction or magnitude of effect estimates). On the basis of grades from the 5 specific domains, we rated the overall SOE for each intervention and outcome as insufficient, low, moderate, or high. Role of the Funding Source The National Institute on Drug Abuse (NIDA) and Bureau of Justice Assistance (BJA) had no role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; or preparation, review, or approval of the manuscript. Results Figure 1 depicts the literature search and selection process. Seventeen articles met the inclusion criteria; 4 reported nonfatal drug overdoses, and 13 reported fatal drug overdoses. All were published between 2011 and 2018. Three were doctoral dissertations (1921), and 14 were published in peer-reviewed journals (2235). Of note, outcome data from 1 study were extracted from 2 publications (29, 36). Supplement 2 presents the characteristics and Appendix Table 2 the ROB assessments of the studies. Figure 1. Evidence search and selection. PDMP= prescription drug monitoring program. Appendix Table 2. ROB Assessment in Studies That Reported on the Association Between PDMPs and Nonfatal and Fatal Drug Overdoses The Table shows the various PDMP configurations evaluated in the 17 studies. Of these studies, 8 examined PDMP implementation in general (21, 29, 3035), 2 looked at program features alone (23, 24), 5 analyzed both PDMP implementation and program features (19, 20, 22, 27, 28), 1 investigated PDMP implementation with mandated provider review combined with pain clinic laws (25), and 1 assessed PDMP robustness (26). The study that examined robustness generated a score of PDMP administrative strength or robustness by assigning weights to specific administrative features on the basis of extant evidence, or expert judgment if evidence was lacking, regarding the expected effect of the characteristic on prescribing or overdose, then summing the weights for a PDMP in a given state for a particular year (26). Among the 7 studies that examined program features, whether alone (22, 24) or in addition to PDMPs in general (19, 20, 22, 27, 28), mandatory provider use of or registration for the PDMP was the most frequently evaluated administrative feature, with 1 study examining the association with nonfatal overdoses (28), 4 studies investigating the association with fatal overdoses (20, 22, 24, 27), and 1 study looking at the association with both nonfatal and fatal overdoses (23). In addition, 2 studies examined state authorization for providers to access PDMP data (20, 22), 2 focused on proactive repo