Characteristics of adults seeking medical marijuana certification

Characteristics of adults seeking medical marijuana certification

Drug and Alcohol Dependence 132 (2013) 654–659 Contents lists available at ScienceDirect Drug and Alcohol Dependence journal homepage: www.elsevier...

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Drug and Alcohol Dependence 132 (2013) 654–659

Contents lists available at ScienceDirect

Drug and Alcohol Dependence journal homepage: www.elsevier.com/locate/drugalcdep

Characteristics of adults seeking medical marijuana certification Mark A. Ilgen a,b,∗ , Kipling Bohnert a,b , Felicia Kleinberg a,b , Mary Jannausch a,b , Amy S.B. Bohnert a,b , Maureen Walton a,b , Frederic C. Blow a,b a VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), Department of Veterans Affairs Healthcare System, Ann Arbor, MI, United States b Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States

a r t i c l e

i n f o

Article history: Received 9 January 2013 Received in revised form 26 March 2013 Accepted 15 April 2013 Available online 15 May 2013 Keywords: Marijuana Drug dependence Chronic pain Health services

a b s t r a c t Background: Very little is known about medical marijuana users. The present study provides descriptive information on adults seeking medical marijuana and compares individuals seeking medical marijuana for the first time with those renewing their medical marijuana card on measures of substance use, pain and functioning. Methods: Research staff approached patients (n = 348) in the waiting area of a medical marijuana certification clinic. Chi-square and Wilcoxon signed rank tests were used to compare participants who reported that they were seeking medical marijuana for the first time (n = 195) and those who were seeking to renew their access to medical marijuana (n = 153). Results: Returning medical marijuana patients reported a higher prevalence of lifetime cocaine, amphetamine, inhalant and hallucinogen use than first time patients. Rates of recent alcohol misuse and drug use were relatively similar between first time patients and returning patients with the exception of nonmedical use of prescription sedatives and marijuana use. Nonmedical prescription sedative use was more common among first time visitors compared to those seeking renewal (p < 0.05). The frequency of recent marijuana use was higher in returning patients than first time patients (p < 0.0001). Compared to first time patients, returning patients reported somewhat lower current pain level and slightly higher mental health and physical functioning. Conclusions: Study results indicate that differences exist between first time and returning medical marijuana patients. Longitudinal data are needed to characterize trajectories of substance use and functioning in these two groups. Published by Elsevier Ireland Ltd.

1. Introduction Marijuana is the most commonly used schedule I controlled substance in the United States (US; Substance Abuse and Mental Health Services Administration, 2010). Based on national survey data, an estimated 16.7 million individuals 12 years of age or older have used marijuana in the past month (Substance Abuse and Mental Health Services Administration, 2010). Heavier marijuana use has been linked to a number of adverse health and social outcomes, including cannabis dependence, other psychiatric conditions such as psychosis, poor work outcomes, neurocognitive problems, and interpersonal violence (Adefuye et al., 2009; Brodbeck et al., 2006; Brook et al., 2008; Buckner et al., 2011; D’Souza, 2007; Gruber et al.,

∗ Corresponding author at: VA Serious Mental Illness Treatment Resource and Evaluation Center, University of Michigan Department of Psychiatry, North Campus Research Complex, 2800 Plymouth Rd., Building 14, Ann Arbor MI 48109, United States. Tel.: +1 734 845 3646; fax: +1 734 222 7514. E-mail address: [email protected] (M.A. Ilgen). 0376-8716/$ – see front matter Published by Elsevier Ireland Ltd. http://dx.doi.org/10.1016/j.drugalcdep.2013.04.019

2003; Moore et al., 2005; Naar-King et al., 2010; Stinson et al., 2006). In addition, although primarily based on data from adolescents, there is concern that marijuana use could lead to greater utilization of other drugs (Kandel et al., 1992; Wagner and Anthony, 2002). Despite the potential harms associated with use, individual marijuana users report that marijuana is helpful for managing a wide range of conditions and complications including AIDS wasting, spasticity from multiple sclerosis, depression, chronic pain, and nausea associated with chemotherapy (Institute of Medicine, 1999). Arguably, the strongest research base for the medicinal use of marijuana pertains to the treatment of pain. A number of laboratory studies have examined the short-term analgesic effects of marijuana use (Campbell et al., 2001; Institute of Medicine, 1999, 2009; Narang et al., 2008). These studies have generally established that marijuana use is associated with a significant reduction in self-reported pain levels when compared with a placebo. For example, Wilsey et al. (2008) found that pain was more tolerable with higher cumulative doses of marijuana than with a placebo in a laboratory setting. Other studies have supported the short term effect of synthetic cannabinoids in reducing pain (Holdcroft et al.,

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1997; Jochimsen et al., 1978; Maurer et al., 1990; Noyes et al., 1975; Staquet et al., 1978). Very little is known about medical marijuana users and the use of medical marijuana for pain management. Most of the limited existing research on medical marijuana use for pain was conducted in either the United Kingdom (UK) or Canada. For example, in one study, 15% of patients presenting to an ambulatory pain clinic in Canada reported the use of marijuana for pain relief (Ware et al., 2003). Of these individuals, 62% reported marijuana use at least weekly and 38% reported use at least daily. Similarly, a survey of adults in the UK identified through patient support groups for pain and multiple sclerosis found that 18.3% of respondents reported past medical marijuana use; medical marijuana users were more likely to be male, younger in age, and using marijuana for nonmedical reasons compared those with pain and multiple sclerosis who did not use medical marijuana (Ware et al., 2005). Opponents of the use of medical marijuana cite lack of Food and Drug Administration oversight, the potential for dependency, risk associated with the route of administration (smoking), potential misuse for recreational purposes, and lack of recommended dosages (Kleber and Dupont, 2012). Despite the controversy about the potential benefits and costs of marijuana, 18 states, and the District of Columbia, have passed laws providing some level of legal protection for the use of marijuana for medical purposes, with California passing the first of its kind in 1996 (Stack and Suddath, 2009; The Associated Press, November 14, 2010). The specific covered conditions vary from state to state, as do the processes through which an individual can obtain, possess, and use the medical marijuana. Regardless, many aspects of medical marijuana laws are relatively consistent across the states in the following ways: (a) the individual must have one or more qualifying conditions; (b) a physician must document that the individual has one of these qualifying conditions and sign a form that is submitted to the state; (c) the state will then provide a card as verification that a patient qualifies to possess medical marijuana; (d) the patient can then either grow a small amount of marijuana or obtain it from a “caregiver”; and (e) the cards must be renewed on a regular basis to remain valid. Although individual states have legalized marijuana for medical purposes, marijuana use remains illegal under Federal law. The vast majority of what is known about the epidemiology of marijuana use, its correlates, and its potential consequences comes from surveys that do not distinguish between recreational use and use intended for medical purposes. Research is needed to better describe the characteristics of those seeking marijuana for medical purposes and why they report they are seeking medical marijuana cards. Because medical marijuana cards must be renewed at regular intervals, clinics that provide certification for medical marijuana cards include a heterogeneous population of those seeking a card for the first time and those seeking to renew their medical marijuana card. Comparing these two potentially distinct groups provides an important opportunity to better understand how these groups differ in terms of their background characteristics. Additionally, although this is a cross-sectional study, comparing first time medical marijuana patients with those who have had legal access to marijuana for at least one year, provides initial descriptive information on the extent to which those with prior legal access have higher rates of substance use, lower pain and better functioning. The present study surveyed adults seeking medical marijuana from a single medical marijuana certification clinic in southwestern Michigan. This study compared patients seeking first-time medical marijuana certification with patients seeking renewal of their medical marijuana certification on measures of lifetime and current substance use, level of marijuana use and marijuana problems, self-reported pain, mental health and physical functioning.

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2. Methods 2.1. Participants The study was based in a single medical marijuana clinic in southwestern Michigan. Patients awaiting an appointment were asked by a research staff member, not employed by the medical marijuana clinic, if they would like to participate in a 15–20 min survey. During the recruitment period, 370 men and women aged 18 years and older were approached and 348 (94.1%) provided verbal consent to participate in this study. This study was approved by the University of Michigan Medical School Institutional Review Board. Remuneration was $20. 2.2. Measures 2.2.1. Frequency of substance use. Modified items from the World Health Organization’s Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) were used to determine if participants reported lifetime and past three-month use/misuse of marijuana, cocaine, sedatives or sleeping pills, street opioids, prescription opioids, amphetamines, hallucinogens, and inhalants (WHO ASSIST Working Group, 2002). Participants were asked if they ever used a specific substance in their lifetime; if they answered “Yes,” they were asked how often they used the substance in the past three-months. Data were recoded to reflect any lifetime or past three-month use of each substance. For marijuana use, we also examined the frequency of past three-month use. 2.2.2. Alcohol problems. The Alcohol Use Disorder Identification Test (AUDIT) was used to assess for problematic alcohol use (Babor et al., 1989). The AUDIT asks participants about quantity and frequency of alcohol use over the past year in addition to questions about potential consequences of alcohol use. Prior research has established the reliability and validity of the AUDIT (Reinert and Allen, 2002) and current guidelines recommend a cut-off of greater than or equal to 8 as the best screen for a current alcohol use disorder (Conigrave et al., 1995). 2.2.3. Nonmedical pain medication use. Four questions from the Current Opioid Misuse Measure (COMM) were used to assess past 30-day nonmedical opioid use (Butler et al., 2007). The COMM was developed for use in pain treatment settings and has been found to have both good test-retest and internal reliability among chronic pain patients (Butler et al., 2007). Because the recommended scoring guidelines for the COMM were developed for a setting that is quite different from a medical marijuana clinic, the present study used a subset of items from the COMM which were recoded to create an indicator of any past 30-day nonmedical opioid use. Specifically, the following questions (all pertaining to the past 30 days) were used: (1) “How often have you needed to take pain medications belonging to someone else?”; (2) “How often have you had to take more of your pain medication than prescribed?”; (3) “How often have you borrowed pain medication from someone else?”; (4) How often have you used your pain medication for symptoms other than for pain?”. Each of these items included the following response options: “never”; “rarely”, “sometimes”, “often”, or “very often.” For the present study, if a participant gave any response other than “never” for any of the four COMM questions, they were coded as having engaged in nonmedical opioid use in the past 30 days. Additionally, participants were asked to rate the following two statements “I am trying to use prescription pain medications for nonmedical reasons less often than I used to” and “I am trying to use prescription pain medications for pain relief less often than I used to” on a five point scale. Responses were recoded to indicate either “strongly agree” or “agree” versus “neither agree or disagree”, “disagree” or “strongly disagree”. 2.2.4. Pain level. The Numeric Rating Scale (NRS) was used to assess pain level on an 11-point scale (0 = no pain, 10 = worst pain imaginable) (Farrar et al., 2001). Two questions were asked: (1) average pain over the past 30 days and (2) current pain level. 2.2.5. Functioning. The Short Form-12 Health Survey (SF-12) was used to measure emotional and physical functioning (Ware et al., 1995, 1996). The mental component score (MCS) measures mental health symptoms and the impact of these symptoms on one’s daily life. The physical component score (PCS) measures key physical health problems and the degree to which the individual perceives that these problems interfere with their daily activities. 2.3. Data analyses Prior to analysis, frequencies and univariate distributions were evaluated for important demographic characteristics, and categorical responses with low cell counts were consolidated, when necessary, to assure adequate within-cell sample size of planned chi-square tests (e.g., the response options ‘8th grade or less’, ‘some high school’ and ‘high school graduate or GED’ were combined into the category of ‘high school or GED or less’). Frequencies and percentages of substance use, pain and functioning were calculated for the overall sample; group frequencies and means were compared via chi-square and Wilcoxon signed-rank tests, respectively, to analyze differences between those who were seeking medical marijuana certification

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Table 1 Demographic characteristics, overall and comparing patients seeking first-time medical marijuana certification to patients seeking renewal of their medical marijuana certification.

Male gendera Age (years)b 18–30 31–40 41–50 51+ Caucasian racec Education: H.S./GED or less d Married/partnered e Unemployedf,h a b c d e f g h

p-valueg

Overall

Type of visit

n (%)

First visit (n = 195) n (%)

230 (66%)

118 (60%)

112 (73%)

82 (24%) 91 (26%) 81 (23%) 92 (27%) 289 (83%) 136 (39%) 174 (50%) 164 (48%)

56 (29%) 44 (23%) 45 (23%) 49 (25%) 159 (82%) 87 (45%) 92 (47%) 101 (52%)

26 (17%) 47 (31%) 36 (24%) 43 (28%) 130 (85%) 49 (32%) 82 (54%) 63 (41%)

Renewal (n = 153) n (%) 0.02 NS

NS 0.02 NS NS

Overall n = 348. Overall n = 346. Overall n = 345. Overall n = 347. Overall n = 344. Overall n = 343. Based on Chi-square. Also includes disabled, retired, and student.

for the first time and those who were seeking to renew their medical marijuana certification. Twenty-seven participants did not complete all or a portion of the ASSIST, the primary measure to assess substance use. In addition, 5 participants had incomplete demographic information. For all analyses, the total number of respondents with available data was provided and utilized for statistical comparisons between groups.

3. Results 3.1. Demographics On average, participants in this study were 41.5 years of age (SD = 12.6), with half of them at least 50 years of age (Table 1). Additionally, the sample was 66.1% male (n = 230), with the majority of participants describing their race/ethnicity as white (83.8%, n = 289), while 8.1% (n = 28) self-identified as African-American, and the remainder identified as Asian, American Indian, or another race/ethnicity. Only 51.4% (n = 179) of participants were employed, and 50.0% (n = 174) reported that they had a domestic partner. Fifty-six percent (n = 195) of participants reported that they were seeking certification for a medical marijuana card for the first time and the remaining 44.0% (n = 153) reported that they were seeking to renew an existing medical marijuana card. 3.2. Reasons for seeking medical marijuana The vast majority (87%, 303/348) of participants reported that they were seeking medical marijuana for pain relief, either alone or in conjunction with other reasons. Relatively few participants (9.8% of 348) reported only non-pain reasons for seeking medical marijuana and 9 (3% of 348) declined to answer the question. The other reasons for seeking medical marijuana in this sample were: spasms (n = 66), nausea (n = 41), musculoskeletal problems (n = 23), neurological (n = 18), cancer (n = 12), gastrointestinal problems (n = 11), glaucoma (n = 10) or chronic infection (HIV and Hepatitis C; n = 8). 3.3. Non-marijuana substance use Most participants reported alcohol use within their lifetime (89%, n = 294/329; Table 2). Approximately 40% (n = 131/327) of the sample reported nonmedical use of opioids in their lifetime. Other commonly used substances were hallucinogens (38%, n = 121/321) and cocaine (35%, n = 116/324). Lifetime substance use was significantly greater among patients seeking to receive certification to

renew their medical marijuana card relative to first time patients for hallucinogens (p = 0.02), cocaine (p < 0.0001), amphetamines (p < 0.001), inhalants (p < 0.0001), and heroin (p = 0.03), but not for alcohol or nonmedical use of prescription opioids. During the past 3-months, 63% (n = 209/329) of participants reported at least some alcohol use and 13% (n = 43/336) reported drinking at levels that were potentially problematic according to the AUDIT. Approximately 20% (n = 67/327) of participants reported nonmedical prescription opioid use on the ASSIST and the remainder of substances used were used relatively infrequently (i.e., reported by less than 10% of the sample). Nonmedical use of prescription sedatives was more commonly used among first-time visitors compared to those renewing their medical marijuana card (p = 0.02). There were no other significant differences in the proportion of first-time visitors seeking medical marijuana certification and those visiting to renew with respect to past 3-month use of non-marijuana substances. Using recoded items from the COMM, a majority (68%, n = 230/336) of respondents reported they used prescription opioids differently than what was prescribed (i.e., more than prescribed, used or borrowed medications belonging to someone else, or used medications for reasons other than pain relief), within the last month. First time and returning visitors seeking medical marijuana certification did not differ significantly in their report of nonmedical opioid use on this measure. Forty-four percent (n = 161) of all visitors indicated they wanted to reduce their use of prescription pain medications; of these, 45% (n = 148) wanted to reduce their prescription opioid use for pain management and 20% (n = 66) reported a desire to reduce their use of opioids for non-medical reasons. 3.4. Marijuana use Lifetime marijuana use was common in all participants (96%, n = 317/331; Table 3), with a modestly higher proportion for returning visitors, compared to first-time visitors (99% vs. 93%; p = 0.01). Within the three-months prior to the interview, 61% (n = 195/317) of those who ever used marijuana reported daily or almost daily use. For renewing visitors, the proportion was 76% (n = 106/139), compared with 51% (n = 89/174) of first-time visitors. Approximately 8% of all participants (n = 27/317) reported that they had not used marijuana in the past three-months. Overall, returning visitors seeking renewal of their certification were more likely to

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Table 2 Patterns of lifetime and recent use among substances other than marijuana. Overall

Lifetime substance use From the ASSIST Alcohola Prescription opioidsb Hallucinogensc Cocained Amphetaminese Prescription sedativesd Inhalantsf Street opioidse Recent substance use From the ASSIST Alcohola Prescription opioidsb Hallucinogensc Cocained Amphetaminese Prescription Sedativesd Inhalantsf Street opioidse From the AUDIT Alcohol score ≥ 8g From the COMM Nonmedical use of prescription opioidsg Desire to reduce opioid use For nonmedical reasonsh For pain reliefh a b c d e f g h i

p-valuei

Type of visit First visit (n = 195)

Renewal (n = 153)

292 (89%) 131 (40%) 121 (38%) 116 (36%) 81 (25%) 80 (25%) 28 (9%) 37 (11%)

165 (88%) 68 (36%) 59 (32%) 48 (26%) 33 (18%) 39 (21%) 6 (3%) 15 (8%)

127 (90%) 63 (45%) 62 (45%) 68 (49%) 48 (34%) 41 (30%) 22 (16%) 22 (16%)

209 (63%) 67 (20%) 18 (6%) 9 (3%) 11 (3%) 28 (9%) 4 (1%) 5 (2%)

115 (61%) 38 (20%) 11 (6%) 3 (2%) 7 (4%) 19 (10%) 1 (1%) 3 (2%)

94 (66%) 29 (19%) 7 (5%) 6 (4%) 4 (3%) 9 (6%) 3 (2%) 2 (1%)

NS NS NS NS NS 0.02 NS NS

43 (13%)

28 (15%)

15 (10%)

NS

230 (68%)

135 (71%)

95 (65%)

NS

66 (20%) 148 (45%)

39 (21%) 75 (40%)

27 (19%) 73 (51%)

NS NS

NS NS 0.02 <0.0001 0.001 NS 0.0001 0.03

Overall n = 329. Overall n = 327. Overall n = 321. Overall n = 324. Overall n = 322. Overall n = 318. Overall n = 336. Overall n = 330. Chi-square tests based on those responding.

have used marijuana at least weekly, or daily (p < 0.0001), within the past three-months.

on both scales than did returning visitors [PCS: 35.1 (8.2) vs. 37.9 (9.1); p < 0.01; MCS: 47.3 (11.6) vs. 50.0 (11.1); p < 0.05], indicating worse functioning on both scales.

3.5. Functioning and pain 4. Discussion Participants rated both their current pain and average pain level over the past 30 days (Table 4). Mean current pain levels were 5.8 (SD = 2.3); first-time visitors reported higher current pain ratings (mean = 6.2, SD = 2.2; p = 0.04) than did returning visitors (mean = 5.5, SD = 2.4). Average pain levels in the past thirty days were not significantly different. Mean PCS and MCS scores of the SF-12 were 36.4 (SD = 8.7) and 48.5 (SD = 11.4), respectively. First-time visitors seeking certification to obtain the medical marijuana card scored significantly lower

As more states legalize marijuana for medical reasons, it is essential to characterize the patient population that is seeking medical marijuana and to document the potential risks and benefits of medical marijuana use. This study takes a first step in this process by describing a sample of adults seeking medical marijuana at Table 4 Functioning and pain level.

Table 3 Patterns of Marijuana use, lifetime and in past three-months. Marijuana use

Lifetimea Recentb Daily or almost daily Weekly Monthly Once or twice Never a b c d

Overall

317 (96%) 312 (98%) 195 (61%) 47 (15%) 21 (7%) 23 (7%) 27 (9%)

Type of visit

p-value

First visit

Renewal

177 (93%) 174 89 (51%) 31 (18%) 12 (7%) 18 (10%) 24 (14%)

140 (99%) 139 106 (76%) 16 (11%) 9 (6%) 5 (4%) 4 (2%)

overall n = 331. overall n = 317. Chi-square test, based on those responding to ASSIST. Cochran-Armitage test for trend.

0.01c – <0.0001d

Pain level (NRS) Currenta Past 30 daysb SF-12e Physical component (mean, SD)c Mental component (mean, SD)c a b c d e 3

Overall

Type of visit

Mean (SD)

First visit Mean (SD)

Renewal Mean (SD)

5.8 (2.3) 6.8 (1.9)

6.0 (2.2) 7.0 (1.7)

5.5 (2.4) 6.5 (2.1)

36.4 (8.7)

35.1 (8.2)

37.9 (9.1)

<0.013

48.5 (11.4)

47.3 (11.6)

50.0 (11.1)

0.033

Overall n = 331. Overall n = 332. Overall n = 342. Based on Wilcoxon signed-rank test. Lower scores indicate worse functioning. 0.005.

p-value

0.04d NS1

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one certification clinic in Michigan and comparing those who were seeking medical marijuana certification for the first time with those who were renewing their certification. The vast majority (87%) of patients seeking medical marijuana, either for the first time or as a renewal, reported that they plan on using marijuana for pain management. When examining the differences between patients seeking a card for the first time and returning patients, rates of recent substance use were relatively similar with the exception of nonmedical use of prescription sedatives and marijuana use. Prescription sedative use was more common in first time patients and marijuana was used on a more frequent basis among returning patients. In addition, returning patients reported somewhat lower scores on measures of current pain and slightly higher scores on measures of mental health and physical functioning than did first time patients; although, the magnitude of these differences was modest. Overall, the findings point to differences between first time and returning patients and highlight the need for longitudinal data to examine trajectories of substance use, pain and functioning after obtaining or renewing a medical marijuana card. The majority of the patients in this study reported using illegal drugs within their lifetime. Only an estimated 7% of first-time patients seeking medical marijuana certification had never used cannabis in their lifetime. This could reflect weaknesses in the self-report measure of marijuana use or these individuals could represent a distinct group of marijuana-naïve patients seen in this setting. Future work with a larger sample could explore the unique characteristics of this group. Of those who reported marijuana use, it is unknown whether the use was for recreational and/or medical reasons. In addition, the estimates of other lifetime drug use obtained in this sample of patients seeking medical marijuana certification are notably higher than estimates reported for similarly aged individuals participating in national surveys (Substance Abuse and Mental Health Services Administration, 2011). When examining current drug use, with the exception of marijuana use and nonmedical prescription opioid use, the rates of past three-month drug use was higher in this sample than national averages, yet was still relatively uncommon. For example, 3% of participants reported past three-month cocaine use, 3% reported amphetamine use and 1% reported heroin use. The vast majority of participants reported past three-month marijuana use; although it is notable that, among first time medical marijuana patients seeking certification, 14% reported no past three-month use and 10% reported only using ‘once or twice’ in the past three-months. Our results also indicated that patients seeking certification to renew their medical marijuana card were more likely to have used cocaine, amphetamines and heroin during their lifetime than those seeking certification for the first time patients. The higher rates of lifetime substance use in the renewing patients may reflect the fact that they acted more quickly to obtain a medical marijuana card when the medical marijuana program began in the State of Michigan. These “early adopters” may be more comfortable seeking medical marijuana if they had prior experience with substance use. Reports of recent substance use were relatively similar between those who were seeking medical marijuana for the first time and those who were renewing their certification. Although one needs to be careful interpreting the lack of differences between these two groups in terms of current use, the present data do not provide any clear indication that obtaining a medical marijuana card is associated with a large increase in the use of drugs other than marijuana. Those who are returning to a medical marijuana certification clinic clearly have more frequent recent marijuana use than patients visiting for the first time. Further, the present data do not allow for the identification of whether this use was purely for medical reasons, for recreational purposes, or for both. Thus, measures are needed that assess misuse of marijuana for this population that can distinguish between different reasons for use. Unfortunately,

measures such as these are difficult to develop because there are no clear guidelines for what constitutes the appropriate quantity or frequency of marijuana use for legitimate medical reasons and whether these differ by presenting problem. Recent misuse of prescription opioids was common and was endorsed by between 20% and 69% of the sample, depending on the measure. A sizable portion of patients reported a desire to cut down their use of opioids for either nonmedical reasons (20%) or for pain relief (45%), suggesting a fairly high level of dissatisfaction with opioids for pain relief and/or the perception that it is important to reduce or limit their use. This may have motivated patients, at least in part, to seek alternative forms of care, such as obtaining a medical marijuana card, in the first place. However, the lack of differences seen between first time and returning patients seeking certification for a medical marijuana card, with respect to measures of current nonmedical use of opioids and of desire to reduce opioid use, suggest that access to medical marijuana may not substantially impact levels of prescription opioid use or misuse. Either way, these results highlight a level of concern among patients about opioids and the need to make patients aware of alternative methods for managing chronic pain that do not involve opioids. The findings from the present study also highlight the salience of pain as a common health condition experienced by the medical marijuana patient group. Overall, the vast majority (87%) of patients reported that severe or chronic pain was the reason for seeking medical marijuana; the percentage was even greater among firsttime visitors (91%) to the clinic. High pain levels from the NRS were also noted for the two groups. It is possible that some participants may have reported pain as a way to obtain a medical marijuana card because it is subjective and it is difficult to disprove. Nonetheless, the importance of pain and pain-related conditions has been noted previously in the limited medical marijuana literature. For example, in a national survey of medical marijuana use in the United Kingdom, pain and pain-related disorders were among the most commonly reported medical reasons for using marijuana (Ware et al., 2005). In another study, medical marijuana patients in Washington reported that intractable pain was the most common qualifying diagnosis for medical marijuana; however, the percentage reporting this condition was lower (25%) than in the present study (Aggarwal et al., in press). Moreover, these findings may not be surprising given evidence from existing laboratory studies that have found that marijuana use is associated with reductions in selfreported pain levels when compared to a placebo (Wilsey et al., 2008). In the present study, returning patients reported slightly lower current pain than first time patients. This is consistent with the interpretation that access to, and use of, marijuana among those who already had a medical marijuana card could have resulted in reductions in the level of pain. However, the overall differences between pain scores was small and the cross-sectional and observational nature of the data do not allow for a direct test of the hypothesis that access to medical marijuana caused returning patients to have reduced pain. Of additional note, self-reported functioning was relatively poor for patients seeking medical marijuana certification in this study. For example, 41% of the patients in the present study rated their general health as “fair” or “poor.” This estimate is noticeably higher (indicating worse health) than the estimate for “fair” or “poor” general health among adult respondents in the 2011 Michigan sample of the Behavioral Risk Factor Survey, which was 17.2% (Fussman, 2012). It is possible that the lower levels of functioning in medical marijuana clinics indicate that these patients have significant medical complications that have not been successfully managed within traditional treatment settings. It may also be that the frequent use of medical marijuana contributed to the lower functioning of patients seen in this setting. Irrespective of the cause of poor functioning, the present findings highlight that patients seeking medical marijuana

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face a number of physical and mental health-related challenges and could benefit from future efforts to improve both their physical and psychiatric functioning. Those returning for a renewal of their certification to obtain a medical marijuana card reported higher medical and mental health functioning than those seeking certification for a card for the first time. Although this is consistent with the interpretation that access to a medical marijuana card is associated with improved functioning, the reported differences were relatively small and may not be clinically significant. Further, because the data are cross-sectional and first time and returning patients clearly differ on a number of domains, it is not possible to determine the extent to which these differences can be attributed to medical marijuana use. The present findings should be interpreted with caution for several reasons. First, the study was based in a single clinic and the results may not be generalizable to other settings. Additionally, all measures were self-report and participants’ beliefs about the merits of medical marijuana may have influenced their reporting of their pain, substance use and functioning. Future work on this topic should utilize structured clinical interviews as well as objective measures of pain tolerance, substance use and functioning. Also, the study did not obtain any medical records from the participating medical marijuana certification clinic, so it is unknown whether the physician recommended a medical marijuana card for all the patients participating in the study. Despite these limitations, the present study is one of the first to characterize the patient population seeking medical marijuana certification in the United States. These findings point to high levels of previous drug use and pain, as well as poor overall health, among both first-time patients and those seeking renewal of their medical marijuana card. Further research is needed to examine whether marijuana, used for medical purposes, is associated with changes in medical conditions, pain, and functioning among these patients. References Adefuye, A., Abiona, T., Balogun, J., Lukobo-Durrell, M., 2009. HIV sexual risk behaviors and perception of risk among college students: implications for planning interventions. BMC Public Health 9, 281. Aggarwal, S.K., Carter, G.T., Sullivan, M.D., ZumBrunnen, C., Morrill, R., Mayer, J.D. Prospectively surveying health-related quality of life and symptom relief in a lot-based sample of medical cannabis-using patients in urban Washington state reveals managed chronic illness and debility. Am. J. Hosp. Palliat. Care, http://www.ncbi.nlm.nih.gov/pubmed/22887696, in press. Babor, T.F., De La Fuente, J.R., Saunders, J., Grant, M., 1989. AUDIT—the Alcohol Use Disorders Identification Test: Guidelines for Use in Primary Health Care. World Health Organization, Geneva. Brodbeck, J., Matter, M., Moggi, F., 2006. Association between cannabis use and sexual risk behavior among young heterosexual adults. AIDS Behav. 10, 599–605. Brook, J.S., Stimmel, M.A., Zhang, C., Brook, D.W., 2008. The association between earlier marijuana use and subsequent academic achievement and health problems: a longitudinal study. Am. J. Addict. 17, 155–160. Buckner, J.D., Heimberg, R.G., Schmidt, N.B., 2011. Social anxiety and marijuana-related problems: the role of social avoidance. Addict. Behav. 36, 129–132. Butler, S.F., Budman, S.H., Fernandez, K.C., Houle, B., Benoit, C., Katz, N., Jamison, R.N., 2007. Development and validation of the current opioid misuse measure. Pain 130, 144–156. Campbell, F.A., Tramer, M.R., Carroll, D., Reynolds, D.J., Moore, R.A., McQuay, H.J., 2001. Are cannabinoids an effective and safe treatment option in the management of pain? A qualitative systematic review. BMJ 323, 13–16.

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