Magdalena Cerdá

Medical marijuana laws in 50 states: Investigating the relationship between state legalization of medical marijuana and marijuana use, abuse and dependence

BACKGROUND Marijuana is the most frequently used illicit substance in the United States. Little is known of the role that macro-level factors, including community norms and laws related to substance use, play in determining marijuana use, abuse and dependence. We tested the relationship between state-level legalization of medical marijuana and marijuana use, abuse, and dependence. METHODS We used the second wave of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a national survey of adults aged 18+ (n=34,653). Selected analyses were replicated using the National Survey on Drug Use and Health (NSDUH), a yearly survey of ∼68,000 individuals aged 12+. We measured past-year cannabis use and DSM-IV abuse/dependence. RESULTS In NESARC, residents of states with medical marijuana laws had higher odds of marijuana use (OR: 1.92; 95% CI: 1.49-2.47) and marijuana abuse/dependence (OR: 1.81; 95% CI: 1.22-2.67) than residents of states without such laws. Marijuana abuse/dependence was not more prevalent among marijuana users in these states (OR: 1.03; 95% CI: 0.67-1.60), suggesting that the higher risk for marijuana abuse/dependence in these states was accounted for by higher rates of use. In NSDUH, states that legalized medical marijuana also had higher rates of marijuana use. CONCLUSIONS States that legalized medical marijuana had higher rates of marijuana use. Future research needs to examine whether the association is causal, or is due to an underlying common cause, such as community norms supportive of the legalization of medical marijuana and of marijuana use.

Adolescent Marijuana Use from 2002 to 2008: Higher in States with Medical Marijuana Laws, Cause Still Unclear

PURPOSE Since 1996, 16 states have legalized marijuana use for medical purposes. The current study provides a scientific assessment of the association of medical marijuana laws (MML) and adolescent marijuana use using national data. METHOD State representative survey data on approximately 23,000 12-17 year olds were collected by the National Survey on Drug Use and Health annually from 2002-2008. Yearly state-specific estimates of prevalence of past-month marijuana use and perception of its riskiness were statistically tested for differences between states with and without MML by year and across years. RESULTS States with MML had higher average adolescent marijuana use, 8.68% (95% CI: 7.95-9.42) and lower perception of riskiness, during the period 2002-2008 compared to states without MML, 6.94% (95% CI: 6.60-7.28%). In the eight states that passed MML since 2004, in the years prior to MML passage, there was already a higher prevalence of use and lower perceptions of risk in those states compared to states that have not passed MML. CONCLUSIONS While the most likely of several possible explanations for higher adolescent marijuana use and lower perceptions of risk in MML states cannot be determined from the current study, results clearly suggest the need for more empirically-based research on this topic.

Medical marijuana laws and adolescent marijuana use in the USA from 1991 to 2014: results from annual, repeated cross-sectional surveys

BACKGROUND Adolescent use of marijuana is associated with adverse later effects, so the identification of factors underlying adolescent use is of substantial public health importance. The relationship between US state laws that permit marijuana for medical purposes and adolescent marijuana use has been controversial. Such laws could convey a message about marijuana acceptability that increases its use soon after passage, even if implementation is delayed or the law narrowly restricts its use. We used 24 years of national data from the USA to examine the relationship between state medical marijuana laws and adolescent use of marijuana. METHODS Using a multistage, random-sampling design with replacement, the Monitoring the Future study conducts annual national surveys of 8th, 10th, and 12th-grade students (modal ages 13-14, 15-16, and 17-18 years, respectively), in around 400 schools per year. Students complete self-administered questionnaires that include questions on marijuana use. We analysed data from 1 098 270 adolescents surveyed between 1991 and 2014. The primary outcome of this analysis was any marijuana use in the previous 30 days. We used multilevel regression modelling with adolescents nested within states to examine two questions. The first was whether marijuana use was higher overall in states that ever passed a medical marijuana law up to 2014. The second was whether the risk of marijuana use changed after passage of medical marijuana laws. Control covariates included individual, school, and state-level characteristics. FINDINGS Marijuana use was more prevalent in states that passed a medical marijuana law any time up to 2014 than in other states (adjusted prevalence 15·87% vs 13·27%; adjusted odds ratio [OR] 1·27, 95% CI 1·07-1·51; p=0·0057). However, the risk of marijuana use in states before passing medical marijuana laws did not differ significantly from the risk after medical marijuana laws were passed (adjusted prevalence 16·25% vs 15·45%; adjusted OR 0·92, 95% CI 0·82-1·04; p=0·185). Results were generally robust across sensitivity analyses, including redefining marijuana use as any use in the previous year or frequency of use, and reanalysing medical marijuana laws for delayed effects or for variation in provisions for dispensaries. INTERPRETATION Our findings, consistent with previous evidence, suggest that passage of state medical marijuana laws does not increase adolescent use of marijuana. However, overall, adolescent use is higher in states that ever passed such a law than in other states. State-level risk factors other than medical marijuana laws could contribute to both marijuana use and the passage of medical marijuana laws, and such factors warrant investigation. FUNDING US National Institute on Drug Abuse, Columbia University Mailman School of Public Health, New York State Psychiatric Institute.

The relationship between neighborhood poverty and alcohol use: estimation by marginal structural models

Background: Previous studies on the relationship of neighborhood disadvantage with alcohol use or misuse have often controlled for individual characteristics on the causal pathway, such as income—thus potentially underestimating the relationship between disadvantage and alcohol consumption. Methods: We used data from the Coronary Artery Risk Development in Young Adults study of 5115 adults aged 18–30 years at baseline and interviewed 7 times between 1985 and 2006. We estimated marginal structural models using inverse probability-of-treatment and censoring weights to assess the association between point-in-time/cumulative exposure to neighborhood poverty (proportion of census tract residents living in poverty) and alcohol use/binging, after accounting for time-dependent confounders including income, education, and occupation. Results: The log-normal model was used to estimate treatment weights while accounting for highly-skewed continuous neighborhood poverty data. In the weighted model, a one-unit increase in neighborhood poverty at the prior examination was associated with a 86% increase in the odds of binging (OR = 1.86 [95% confidence interval = 1.14–3.03]); the estimate from a standard generalized-estimating-equations model controlling for baseline and time-varying covariates was 1.47 (0.96–2.25). The inverse probability-of-treatment and censoring weighted estimate of the relative increase in the number of weekly drinks in the past year associated with cumulative neighborhood poverty was 1.53 (1.02–2.27); the estimate from a standard model was 1.16 (0.83–1.62). Conclusions: Cumulative and point-in-time measures of neighborhood poverty are important predictors of alcohol consumption. Estimators that more closely approximate a causal effect of neighborhood poverty on alcohol provided a stronger estimate than estimators from traditional regression models.

Comorbid Forms of Psychopathology: Key Patterns and Future Research Directions

The purpose of this review is to systematically appraise the peer-reviewed literature about clustered forms of psychopathology and to present a framework that can be useful for studying comorbid psychiatric disorders. The review focuses on four of the most prevalent types of mental health problems: anxiety, depression, conduct disorder, and substance abuse. The authors summarize existing empirical research on the distribution of concurrent and sequential comorbidity in children and adolescents and in adults, and they review existing knowledge about exogenous risk factors that influence comorbidity. The authors include articles that used a longitudinal study design and used psychiatric definitions of the disorders. A total of 58 articles met the inclusion criteria and were assessed. Current evidence demonstrates a reciprocal, sequential relation between most comorbid pairs, although the mechanisms that mediate such links remain to be explained. Methodological concerns include the inconsistency of measurement of the disorders across studies, small sample sizes, and restricted follow-up times. Given the significant mental health burden placed by comorbid disorders, and their high prevalence across populations, research on the key risk factors for clustering of psychopathology is needed.

Trauma Exposure and Posttraumatic Stress Disorder Symptoms Predict Onset of Cardiovascular Events in Women

Background— Psychological stress is a proposed risk factor for cardiovascular disease (CVD), and posttraumatic stress disorder (PTSD), the sentinel stress-related mental disorder, occurs twice as frequently in women as men. However, whether PTSD contributes to CVD risk in women is not established. Methods and Results— We examined trauma exposure and PTSD symptoms in relation to incident CVD over a 20-year period in 49 978 women in the Nurses’ Health Study II. Proportional hazards models estimated hazard ratios and 95% confidence intervals for CVD events confirmed by additional information or medical record review (n=548, including myocardial infarction [n=277] and stroke [n=271]). Trauma exposure and PTSD symptoms were assessed by using the Brief Trauma Questionnaire and a PTSD screen. In comparison with no trauma exposure, endorsing ≥4 PTSD symptoms was associated with increased CVD risk after adjusting for age, family history, and childhood factors (hazard ratio,1.60; 95% confidence interval, 1.20–2.13). Being trauma-exposed and endorsing no PTSD symptoms was associated with elevated CVD risk (hazard ratio, 1.45; 95% confidence interval, 1.15–1.83), although being trauma-exposed and endorsing 1 to 3 PTSD symptoms was not. After adjusting for adult health behaviors and medical risk factors, this pattern of findings was maintained. Health behaviors and medical risk factors accounted for 14% of the trauma/no symptoms–CVD association and 47% of the trauma/4+ symptoms–CVD association. Conclusion— Trauma exposure and elevated PTSD symptoms may increase the risk of CVD in this population of women. These findings suggest that screening for CVD risk and reducing health risk behaviors in trauma-exposed women may be promising avenues for prevention and intervention.

Barrios and Burbs: Residential Context and Health-Risk Behaviors among Angeleno Adolescents.

The increasing size of the Latino immigrant population in the United States underscores the need for a more complete understanding of the role that social context plays in influencing the health of immigrants and their children. This analysis explores the possibility that residential location influences the health-risk behaviors of Latino youth in Los Angeles County, California. The data come from the Los Angeles Family and Neighborhood Survey. We apply multivariate, multilevel Rasch models to two scales of adolescent health-risk behaviors (substance use and delinquency). The findings suggest that residence in Census tracts characterized by above-county-average levels of Latinos and above-county-average levels of poverty is associated with increased odds of health-risk behaviors for Latino adolescents, particularly for those born in the United States. The findings lend support to the contention, put forth in the segmented assimilation literature, that disadvantaged urban contexts increase the risk that U.S.-born children of immigrants will experience downward assimilation.

Genetic and environmental influences on psychiatric comorbidity: a systematic review.

BACKGROUND The purpose of this review is to systematically appraise the peer-reviewed literature about the genetic and environmental determinants of psychiatric comorbidity, focusing on four of the most prevalent types of psychopathology: anxiety disorders, depression, conduct disorder and substance abuse. METHODS We summarize existing empirical research on the relative contribution that genetic, nonshared and shared environmental factors make to the covariance between disorders, and evidence about specific genes and environmental characteristics that are associated with comorbidity. RESULTS Ninety-four articles met the inclusion criteria and were assessed. Genetic factors play a particularly strong role in comorbidity between major depression and generalized anxiety disorder or posttraumatic stress disorder, while the non-shared environments make an important contribution to comorbidity in affective disorders. Genetic and non-shared environmental factors also make a moderate-to-strong contribution to the relationship between CD and SA. A range of candidate genes, such as 5HTTLPR, MAOA, and DRD1-DRD4, as well as others implicated in the central nervous system, has been implicated in psychiatric comorbidity. Pivotal social factors include childhood adversity/life events, family and peer social connections, and socioeconomic and academic difficulties. LIMITATIONS Methodological concerns include the use of clinical case-control samples, the focus on a restricted set of individual-level environmental risk factors, and restricted follow-up times. CONCLUSIONS Given the significant mental health burden associated with comorbid disorders, population-based research on modifiable risk factors for psychiatric comorbidity is vital for the design of effective preventive and clinical interventions.

Reducing Violence by Transforming Neighborhoods: A Natural Experiment in Medellín, Colombia

Neighborhood-level interventions provide an opportunity to better understand the impact that neighborhoods have on health. In 2004, municipal authorities in Medellín, Colombia, built a public transit system to connect isolated low-income neighborhoods to the citys urban center. Transit-oriented development was accompanied by municipal investment in neighborhood infrastructure. In this study, the authors examined the effects of this exogenous change in the built environment on violence. Neighborhood conditions and violence were assessed in intervention neighborhoods (n = 25) and comparable control neighborhoods (n = 23) before (2003) and after (2008) completion of the transit project, using a longitudinal sample of 466 residents and homicide records from the Office of the Public Prosecutor. Baseline differences between these groups were of the same magnitude as random assignment of neighborhoods would have generated, and differences that remained after propensity score matching closely resembled imbalances produced by paired randomization. Permutation tests were used to estimate differential change in the outcomes of interest in intervention neighborhoods versus control neighborhoods. The decline in the homicide rate was 66% greater in intervention neighborhoods than in control neighborhoods (rate ratio = 0.33, 95% confidence interval: 0.18, 0.61), and resident reports of violence decreased 75% more in intervention neighborhoods (odds ratio = 0.25, 95% confidence interval 0.11, 0.67). These results show that interventions in neighborhood physical infrastructure can reduce violence.

Prescription opioid mortality trends in New York City, 1990–2006: Examining the emergence of an epidemic

BACKGROUND The drug overdose mortality rate tripled between 1990 and 2006; prescription opioids have driven this epidemic. We examined the period 1990-2006 to inform our understanding of how the current prescription opioid overdose epidemic emerged in urban areas. METHODS We used data from the Office of the Chief Medical Examiner to examine changes in demographic and spatial patterns in overdose fatalities induced by prescription opioids (i.e., analgesics and methadone) in New York City (NYC) in 1990-2006, and what factors were associated with death from prescription opioids vs. heroin, historically the most prevalent form of opioid overdose in urban areas. RESULTS Analgesic-induced overdose fatalities were the only types of overdose fatalities to increase in 1990-2006 in NYC; the fatality rate increased sevenfold from 0.39 in 1990 to 2.7 per 100,000 persons in 2006. Whites and Latinos were the only racial/ethnic groups to exhibit an increase in overdose-related mortality. Relative to heroin overdose decedents, analgesic and methadone overdose decedents were more likely to be female and to concurrently use psychotherapeutic drugs, but less likely to concurrently use alcohol or cocaine. Analgesic overdose decedents were less likely to be Black or Hispanic, while methadone overdose decedents were more likely to be Black or Hispanic in contrast to heroin overdose decedents. CONCLUSIONS The distinct epidemiologic profiles exhibited by analgesic and methadone overdose fatalities highlight the need to define drug-specific public health prevention efforts.