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An important public concern about the impact of recreational cannabis legalization is how it may affect adolescent cannabis use. Prior research on this issue has primarily focused on the implications of medical cannabis legalization for adolescents and used data that cover a relatively short post-legalization period. This study extends this line of research by examining the relationship between recreational cannabis legalization and adolescent cannabis use in Washington State, using the National Survey of Drug Use and Health (NSDHU) data from 2005 to 2019. Based on a quasi-experimental research design, this study found some evidence suggesting a positive effect of recreational legalization on the prevalence of adolescent cannabis use and cannabis initiation. Findings suggest the need to create a cannabis regulatory environment that minimizes adolescent access to this drug. [ABSTRACT FROM AUTHOR]

Purpose: This study aimed to characterize the prevalence and correlates of cannabis use and the methods and reasons for use among recently diagnosed cancer survivors in a population sample within Washington state. Methods: We identified individuals diagnosed with invasive cancers in the prior 6 to 17 months from April 2020 to December 2020 using the Seattle-Puget Sound Surveillance, Epidemiology, and End Results (SEER) cancer registry. Participants (n = 1,515) completed a questionnaire, including demographics, medical history, cannabis use, and other substance use. Cancer characteristics and date of diagnosis were obtained from SEER registry data. We calculated weighted prevalence estimates and logistic regression models to evaluate correlates of cannabis use. Results: Overall, 41.3% of survivors reported cannabis use at any time after diagnosis, most commonly via edibles (60.5%) and smoking (43.8%). The most frequently reported reasons for use were sleep (54.5%), mood, stress, anxiety, and depression (44.3%), pain (42.3%), and recreation (42.3%). Cannabis use was associated with younger age, race (White vs. Asian), less education, former or current smoking, consuming more than 2 alcohol-containing drinks per day, having late-stage cancer, and cancer site. Conclusion: In this first evaluation of cannabis use in a registry-linked, population-based sample of survivors of all cancer types, based in a state where recreational and medical cannabis have been legal for a decade, approximately 2 in 5 survivors reported post-diagnosis use. Given how common cannabis use is among cancer survivors, there is a great need to understand its impact on cancer treatment outcomes and the overall health of cancer survivors. [ABSTRACT FROM AUTHOR]

Background: To address the research question of how simultaneous users of alcohol and cannabis differ from concurrent users in risk of cannabis use problems after the recreational marijuana legalization in Washington State. Methods: We used generalized estimating equations with a Poisson distribution to analyze the association between simultaneous use of alcohol and marijuana (SAM) and cannabis-related problems compared to concurrent use. The data is a longitudinal sample of drinkers and cannabis users (n = 257, 47% female) aged 18 years and older from Washington State in 2014–2016. We adjusted for survey weights to account for differential probability of selection and response rates. The primary outcome is the past-six-month CUDIT problem subscale (ranging from 0 to 28), which is the total score for seven CUDIT problem items, after excluding the three items that covered marijuana use frequency. Covariates include marijuana use frequency (daily/near daily use, regular use, or infrequent use), marijuana daily quantity, alcohol daily volume, panel survey cycle, medical marijuana recommendation, driving time to nearest marijuana outlet, age of marijuana use onset, and other demographics. Results: After adjusting for covariates, we found that compared to concurrent use, SAM was significantly positively associated with CUDIT problem subscale (IRR = 1.68, 95% CI: 1.25–2.27, p < 0.001); daily/near daily use of marijuana was strongly significantly associated with CUDIT problem subscale compared with infrequent use (IRR = 5.1, 2.71–9.57, p < 0.001) or regular use (IRR = 3.05, 1.91–4.85, p < 0.001). Secondary analyses using CUDIT total score as the outcome also showed a significant positive association with SAM compared to concurrent use (IRR = 1.17, 1.02–1.34, p < 0.05). Conclusions: This study highlighted the importance of SAM, in addition to cannabis use frequency for predicting cannabis-related problems. [ABSTRACT FROM AUTHOR]

Background: Cannabis species have a propensity to bioaccumulate toxic heavy metals from their growth media. Increased testing for these metals is required to improve the safety of the legal medical and recreational cannabis industries. However, the current methods used for mandated heavy metals tests are not efficient for a large framework. As a result, there is limited testing capacity, high testing costs, and long wait times for results across North America. Objective: This study aimed to demonstrate that pooling strategies can be used to increase the throughput in cannabis testing labs and reduce some of the strain on the industry. Methods: This paper presents an algorithm to simulate different pooling strategies. The algorithm was applied to real world data sets collected from Washington and California state testing labs. Results: Using a single pooling method, a pool size of three samples on average resulted in a 23.8% reduction in tests required for 100 samples for the Washington lab. For the California lab, pooling four samples on average resulted in a 54.1% reduction in tests required for 100 samples. Conclusion: The algorithms generated from the Washington and California lab data demonstrated that pooled testing strategies can be developed on a case-by-case method to reduce the time, effort, and costs associated with heavy metals tests. Highlights: The benefits of pooled testing will vary depending on the region and rate of contamination seen in each testing lab. Overall, our results demonstrate pooled testing has the potential to reduce the fiscal costs of testing through increased efficiency, allowing increased testing, leading to greater safety. [ABSTRACT FROM AUTHOR]

The pace of changes in state-level cannabis policies in the United States has accelerated since the mid-1990s. While many states have decriminalized the possession of small amounts of cannabis and have allowed cannabis to be used for various medicinal purposes, the most recent landmark change has been the legalization of recreational cannabis. Native American tribes within these states which have legalized recreational cannabis are now exploring the opportunities to engage in this new cannabis industry as a means of bringing economic development to the tribes and creating employment for tribal members. The unique jurisdictional complexities of the federal, state, and tribal relations with regard to legal recreational cannabis are the subject of this paper, with a focus on policies in the State of Washington. [ABSTRACT FROM AUTHOR]

Legal commercial cultivation and processing of cannabis is a rapidly growing industry in multiple countries. However, to date little effort has been made to characterize and identify the various occupational hazards that workers may be facing in the cannabis production industry, including airborne contaminants that may affect the human respiratory system. In the current study, we quantified occupational exposures to particulate matter (PM) and volatile organic compounds (VOCs) in various task zones of two indoor cannabis facilities in Washington State. Full-shift (8-h) area measurements of PM and VOCs were collected in each task zone. Measurement devices were placed near the employee's work area in order to attempt to estimate the personal exposure to the contaminants. In each task zone we measured particle number concentration, particle mass concentration (PMC), cumulative size distribution of the particles, and total terpene mass concentrations. The mean PMCs were greater in task zones that required the employees to manipulate the cannabis plants and materials. The arithmetic mean PMC for the trim task was 60 µg m−3, preroll task was 45 µg m−3, grow task was 42 µg m−3, and the referent office area was 27 µg m−3. When comparing each task zone PMC to the office referent PMC, the trim task, and the preroll task were significantly higher than the referent group (P -values both <0.05). The arithmetic mean terpene mass concentration for the trim task was 36 mg m−3, preroll task was 9.9 mg m−3, grow task was 15 mg m−3, and for the office referent space was 4.9 mg m−3. Compared with the office space, only the trim task area had significantly elevated terpene mass concentrations (P -value <0.01). We observed a weak but statistically significant correlation between PMC and total terpene mass concentrations (rho = 0.42, P < 0.02). Overall, we observed that exposures to respiratory hazards were highest in task zones where cannabis plants and material were manipulated by workers, including the trim, preroll, and the grow task areas. These observations can help inform the employer of the task zones where exposure to respiratory hazards are the highest, and where it may be beneficial to deploy control measures to reduce worker exposures. [ABSTRACT FROM AUTHOR]

Aims: To perform a wastewater‐based analysis to explore the impact of newly legalized retail cannabis sales on its use and to determine if this approach could estimate the size of the legal market place, which began 1 August 2014 in the study area. Design Laboratory study of raw wastewater samples collected and analyzed over the 3‐year period from 2014 to 2016. Setting and Participants: Samples obtained from the two wastewater treatment plants that serviced a municipality of 200 000 people in the state of Washington, USA. Measurements Quantitative analysis of 24‐hour composite influent samples for the metabolite of the active ingredient in cannabis, 11‐nor‐9‐Carboxy‐Δ9‐tetrahydrocannabinol (THC‐COOH) were performed by liquid chromatography coupled to mass spectrometry. Findings Wastewater estimates for THC‐COOH increased by 9% per quarter, suggesting a doubling in cannabis consumption from 1 December 2013 to 31 December 2016. State‐sold THC increased at nearly 70% per quarter, while stores operated from 1 August 2014 to 31 December 2016. Estimating the proportion of the total cannabis market supplied by state‐regulated cannabis from these data is not currently achievable. Conclusion: A wastewater‐based measure of cannabis consumption suggests a significant increase in consumption in Washington, USA following legalization, and that legal sales appear to have displaced a large portion of the illicit market. [ABSTRACT FROM AUTHOR]

Background: Washington is the only U.S. state to recognize and ccrtify the medical marijuana consultant role. Medical marijuana customers have the option to use the services of a consultant for advice on the selection of marijuana products that may benefit a qualifying terminal or debilitating medical condition, the risks and benefits of these products, and the risks and benefits of methods of administration of these products. The purpose of this study was to investigate of the knowledge, practices, and attitudes regarding medical marijuana among certified medical marijuana consultants in Washington State, and to identify sources of information used by medical marijuana consultants to advise patients regarding the use of marijuana for medical conditions. Methods: A cross-sectional mixed-mode survey was administered to a random sample of 360 Washington State medical marijuana consultants selected from the state Department of Health's list of 740 consultants with active certification as of December 2017. Results: Most respondents (84-100%) correctly identified conditions that qualify a patient to receive an authorization to use medical marijuana. Fewer respondents (8-31%) accurately identified conditions that do not qualify a patient to receive a medical marijuana authorization, such as depression and anxiety. Consultants heartily endorsed marijuana for medical conditions and believed it carries little risk. Many felt the required training for the consultant role did not sufficiently prepare them to understand scientific information regarding marijuana benefits and risks, although they expressed reliance on this course for counseling patients. Conclusions: While consultants were generally knowledgeable regarding law and practice, additional training is advised to clarify both current evidence and current health implications of marijuana, especially for mental health conditions. State or national expansion of legal recognition of medical marijuana should include evidence-based training policies for those in positions to influence the public's purchase and use of marijuana for health conditions. [ABSTRACT FROM AUTHOR]

Objective: A small body of work has started developing cannabis use "typologies" for use in treatment and prevention. Two potentially relevant dimensions for classifying cannabis use typologies are medical versus recreational cannabis use and the co-use of cannabis and alcohol. Here we compare alcohol use and related problems between cannabis users with and without medical cannabis recommendations.Method: Data come from a larger general population study in Washington State conducted between January 2014 and October 2016. All participants in the analytic sample (n = 991) reported using both alcohol and cannabis in the past 12 months. The primary exposure was having a medical recommendation for cannabis. Outcomes were past-30-day drinking (drinks/day, frequency of 5+ drinks, and maximum number of drinks in a day) and past-12-month Alcohol Use Disorders Identification Test (AUDIT) scores.Results: Compared with those without medical cannabis recommendations, cannabis users with medical cannabis recommendations had 0.59 times fewer drinks/day, 0.44 times fewer occasions drinking 5+, and 0.78 times the average maximum number of drinks in one day (all ps < .05). Those with a recommendation also had 0.87 times lower AUDIT total scores (p < .05) and 0.57 times lower AUDIT problem scores (p < .01).Conclusions: Cannabis users with medical cannabis recommendations drink less and have fewer alcohol-related problems than those without recommendations, even after adjusting for health status. Future studies should examine nonhealth reasons regarding how medical and nonmedical users use cannabis differently. [ABSTRACT FROM AUTHOR]

• Cannabis has been promoted as an alternative to opioids for pain management. • This study examined associations of cannabis use with non-medical pain reliever misuse onset among young adults. • Non-medical and medical cannabis use was associated with increased risk of non-medical pain reliever misuse onset. • Cannabis use may not be protective against pain reliever misuse and related harms. Little is known about the prospective relationship between cannabis use and pain reliever misuse. This study examined associations of non-medical and medical cannabis use with onset of non-medical pain reliever misuse among young adults in Washington State (WA), where non-medical cannabis is legal. Data were from a cohort-sequential study of adults 18–25 residing in WA. Four annual surveys were used from cohorts recruited in 2014, 2015, and 2016. Participants who had not reported non-medical pain reliever misuse at baseline were included in discrete time survival analyses (N = 4,236). Odds ratios (ORs) were estimated for new onset of non-medical pain reliever misuse in any given follow-up year over the course of three years according to baseline non-medical and medical cannabis use. When included separately in models, non-medical and medical cannabis use at baseline were associated with increased risk of non-medical pain reliever misuse adjusting for demographic characteristics as well as past year cigarette use and alcohol use (non-medical OR = 5.27; 95 % CI: 3.28, 8.48; medical OR = 2.21; 95 % CI: 1.39, 3.52). Including both forms of use in the model, associations of non-medical and medical cannabis use with non-medical pain reliever misuse onset remained (non-medical OR = 4.64; 95 % CI: 2.88, 7.49; medical OR = 1.65; 95 % CI: 1.04, 2.62). Despite claims that cannabis use may reduce opioid use and related harms, findings suggest that cannabis use, including medical use, may not be protective, but instead may increase risk for non-medical pain reliever misuse. [ABSTRACT FROM AUTHOR]

BACKGROUND: Although medical marijuana (MM) may have utility in the supportive care of children with serious illness, it remains controversial. We investigated interdisciplinary provider perspectives on legal MM use in children with cancer. METHODS: We sent a 32-item, cross-sectional survey to 654 pediatric oncology providers in Illinois, Massachusetts, and Washington characterizing MM practices, knowledge, attitudes, and barriers. Forty-eight percent responded; 44% (n = 288) were included in analyses. Providers were stratified by status as legally eligible to certify (ETC) for MM. We used Fisher's exact and Wilcoxon rank tests and univariate and multivariate logistic regression models for group comparisons. RESULTS: The provider median age was 35 years (range 22-70 years); 33% were ETC (83 physicians; 13 Washington state advance practice providers). Thirty percent of providers received >1 request for MM in the previous month. Notably, only 5% of all providers knew state-specific regulations. ETC providers were more likely to know that MM is against federal laws (P < .0001). Whereas most providers (92%) reported willingness to help children with cancer access MM, in adjusted models, ETC providers were less likely to indicate approval of patient MM use by smoking, oral formulations, as cancer-directed therapy, or to manage symptoms (P < .005 for all). Forty-six percent of all providers cited the absence of standards around formulations, potency, or dosing to be the greatest barrier to recommending MM. CONCLUSIONS: Most pediatric oncology providers are willing to consider MM use in children with cancer and receive frequent inquiries. However, ETC providers endorse less favorable attitudes overall. The absence of standards is an important barrier to recommending MM. [ABSTRACT FROM AUTHOR]

Background: Cannabis is purported to alleviate symptoms related to cancer treatment, although the patterns of use among cancer patients are not well known. This study was designed to determine the prevalence and methods of use among cancer patients, the perceived benefits, and the sources of information in a state with legalized cannabis.Methods: A cross-sectional, anonymous survey of adult cancer patients was performed at a National Cancer Institute-designated cancer center in Washington State. Random urine samples for tetrahydrocannabinol provided survey validation.Results: Nine hundred twenty-six of 2737 eligible patients (34%) completed the survey, and the median age was 58 years (interquartile range [IQR], 46-66 years). Most had a strong interest in learning about cannabis during treatment (6 on a 1-10 scale; IQR, 3-10) and wanted information from cancer providers (677 of 911 [74%]). Previous use was common (607 of 926 [66%]); 24% (222 of 926) used cannabis in the last year, and 21% (192 of 926) used cannabis in the last month. Random urine samples found similar percentages of users who reported weekly use (27 of 193 [14%] vs 164 of 926 [18%]). Active users inhaled (153 of 220 [70%]) or consumed edibles (154 of 220 [70%]); 89 (40%) used both modalities. Cannabis was used primarily for physical (165 of 219 [75%]) and neuropsychiatric symptoms (139 of 219 [63%]). Legalization significantly increased the likelihood of use in more than half of the respondents.Conclusions: This study of cancer patients in a state with legalized cannabis found high rates of active use across broad subgroups, and legalization was reported to be important in patients' decision to use. Cancer patients desire but are not receiving information about cannabis use during their treatment from oncology providers. Cancer 2017;123:4488-97. © 2017 The Authors. Cancer published by Wiley Periodicals, Inc. on behalf of American Cancer Society. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. [ABSTRACT FROM AUTHOR]

Background: While medical marijuana use is legal in more than half of U.S. states, evidence is limited about the preparation of physicians-in-training to prescribe medical marijuana. We asked whether current medical school and graduate medical educational training prepare physicians to prescribe medical marijuana.Methods: We conducted a national survey of U.S. medical school curriculum deans, a similar survey of residents and fellows at Washington University in St. Louis, and a query of the Association of American Medical Colleges (AAMC) Curriculum Inventory database for keywords associated with medical marijuana.Results: Surveys were obtained from 101 curriculum deans, and 258 residents and fellows. 145 schools were included in the curriculum search. The majority of deans (66.7%) reported that their graduates were not at all prepared to prescribe medical marijuana, and 25.0% reported that their graduates were not at all prepared to answer questions about medical marijuana. The vast majority of residents and fellows (89.5%) felt not at all prepared to prescribe medical marijuana, while 35.3% felt not at all prepared to answer questions, and 84.9% reported receiving no education in medical school or residency on medical marijuana. Finally, only 9% of medical school curriculums document in the AAMC Curriculum Inventory database content on medical marijuana.Conclusions: Our study highlights a fundamental mismatch between the state-level legalization of medical marijuana and the lack of preparation of physicians-in-training to prescribe it. With even more states on the cusp of legalizing medical marijuana, physician training should adapt to encompass this new reality of medical practice. [ABSTRACT FROM AUTHOR]

Introduction Cannabis users are at higher risk for any mental disorder than the general population. However, there remains a shortage of research that examines the relationship between reluctance to seek mental health treatment and subsequent frequent cannabis use. This study evaluates whether negative attitudes toward mental health treatment (i.e. attitudinal barriers) predict a high frequency of cannabis use and whether using cannabis to cope with mental health symptoms (i.e., coping motives) explains this relationship. Methods Participants were students at Washington State University (WSU) who received violations for illegal cannabis use or possession. Data were collected from participants 60 days after a mandated two-part course for cannabis harm reduction (n = 98). A cross-sectional path analysis was performed to assess whether coping motives mediated the relationship between attitudinal barriers to mental health treatment and frequency of cannabis use after controlling for mental health symptoms. Results Coping motives fully mediated the relationship between negative attitudes toward treatment and frequency of use (indirect effect: β = 0.087, bootstrap CI: 0.016–0.541). The direction of results was confirmed by switching the mediator and criterion variable. The model fit well with the data ( χ 2 (2) = 0.367, p = 0.83, RMSEA = 0.00, CFI = 1, SRMR = 0.008). Conclusions Reluctance to seek mental health treatment may be related to higher levels of cannabis use through coping motives. Addressing attitudes toward mental health treatment may be an alternative way to decrease frequency of use or possibly promote mental health treatment-seeking behaviors when needed. Further studies are needed to confirm the implications of this finding. [ABSTRACT FROM AUTHOR]

Background: Support for the legalization of recreational marijuana continues to increase across the United States and globally. In 2016, recreational marijuana was legalized in the most populous US state of California, as well as three other states. The primary aim of this study was to examine trends in support for recreational marijuana legalization in Washington, a state which has had legal recreational marijuana for almost four years, using data collected over the four years post-legalization. A secondary aim was to examine trends in support for the cultivation of marijuana for personal use.Methods: Data come from geographically representative general population samples of adult (aged 18 and over) Washington residents collected over five timepoints (every six months) between January 2014 and April 2016 (N=4101). Random Digit Dial was used for recruitment. Statistical analyses involved bivariate comparisons of proportions across timepoints and subgroups (defined by age, gender, and marijuana user status), and multivariable logistic regression controlling for timepoint (time) to formally test for trend while controlling for demographic and substance use covariates. All analyses adjusted for probability of selection.Results: Support for legalization in Washington has significantly increased: support was 64.0% (95% CI: 61.2%-67.8%) at timepoint 1 and 77.9% (95% CI: 73.2%-81.9%) at timepoint 5. With each six months' passing, support increased 19% on average. We found no statistically significant change in support for home-growing.Conclusions: Support for marijuana legalization has continued to significantly increase in a state that has experienced the policy change for almost four years. [ABSTRACT FROM AUTHOR]

Despite the federal prohibition against marijuana, state-level recreational use appears to be moving forward. Public opinion is shifting. Following well-publicized state-legalization in Washington and Colorado, states across the US have begun considering similar measures. Since the 2016 election, over 21% of Americans now live in places where recreational marijuana is state-legal, and over 63% of the country permits medical or recreational use at the state level. This paper does not consider whether states should legalize marijuana nor does it weigh all regulatory options available to states. Instead, it considers how states can create a practical framework to regulate recreational marijuana, particularly in a climate of federal uncertainty where marijuana remains illegal. We draw lessons from Colorado and Washington-assuming that other states will adopt similar models and employ commercial, for-profit systems. Considering both the variety of goals that states could adopt and how they interact, we offer recommendations in five areas: cultivation, production, and processing; sale, consumption, and possession; taxes and finance; public health and safety; and governance. We recommend that states implement a relatively restrictive regulatory approach, with a single market for recreational and medical marijuana, if appropriate. This should make marijuana laws easier to enforce, help reduce diversion, and satisfy federal guidance. Moreover, drawing from Colorado and Washington's experience, we suggest a flexible system with robust data collection and performance monitoring that supports a thorough evaluation. This should allow states to "learn as they go"-a must, given the uncertainty surrounding such policy shifts. Of course, a tightly regulated approach will have drawbacks-including a significant illegal market. But political experience teaches that states will be better off loosening a tight market than attempting to tighten a loose one. We also consider a potential role for the federal government under the status quo. [ABSTRACT FROM AUTHOR]

Background and aims Since 2012 four US states have legalized the retail sale of cannabis for recreational use by adults, and more are likely to follow. This report aimed to (1) briefly describe the regulatory regimes so far implemented; (2) outline their plausible effects on cannabis use and cannabis-related harm; and (3) suggest what research is needed to evaluate the public health impact of these policy changes. Method We reviewed the drug policy literature to identify: (1) plausible effects of legalizing adult recreational use on cannabis price and availability; (2) factors that may increase or limit these effects; (3) pointers from studies of the effects of legalizing medical cannabis use; and (4) indicators of cannabis use and cannabis-related harm that can be monitored to assess the effects of these policy changes. Results Legalization of recreational use will probably increase use in the long term, but the magnitude and timing of any increase is uncertain. It will be critical to monitor: cannabis use in household and high school surveys; cannabis sales; the number of cannabis plants legally produced; and the tetrahydrocannabinol (THC) content of cannabis. Indicators of cannabis-related harms that should be monitored include: car crash fatalities and injuries; emergency department presentations; presentations to addiction treatment services; and the prevalence of regular cannabis use among young people in mental health services and the criminal justice system. Conclusions Plausible effects of legalizing recreational cannabis use in the United States include substantially reducing the price of cannabis and increasing heavy use and some types of cannabis-related harm among existing users. In the longer term it may also increase the number of new users. [ABSTRACT FROM AUTHOR]

Aims To describe patterns of cannabis use, the degree of overlap between medicinal and recreational users, and their differential use patterns, modes of consumption and sources of cannabis. Design An ongoing probability-based internet panel maintained by the market research firm GfK Group. Setting Households in Colorado, Washington, Oregon and New Mexico, USA. Participants A total of 2009 individuals from Washington ( n = 787), Oregon ( n = 506), Colorado ( n = 503) and New Mexico ( n = 213). Post stratification sampling weights were provided so that estimates could be made representative of the household population in each of these states. Respondents were aged between 18 and 91 years, with a mean age of 53 years. Methods We compare patterns of cannabis consumption for medicinal and recreational users as well as simultaneous use of alcohol and cannabis. We also examine the extent to which patterns of use differ across states that chose to legalize ( Washington and Colorado) and those that did not ( New Mexico and Oregon). Findings Rates of life-time medical cannabis use are similar in Colorado and Washington (8.8% and 8.2%) but lower in Oregon and New Mexico (6.5% and 1%). Recreational use is considerably higher than medical use across all states (41%), but highest in Oregon and Washington. Approximately 86% of people who report ever using cannabis for medicinal purposes also use it recreationally. Medical users are more likely to vaporize and consume edibles and report a higher amount (in grams) consumed, and spend more money per month than recreational users. Individuals who use cannabis do not commonly use it with alcohol, irrespective of whether they are consuming cannabis recreationally or medically. Fewer than one in five recreational users report simultaneous use of alcohol and cannabis most or all of the time and fewer than 3% of medicinal users report frequent simultaneous use of alcohol and cannabis. Conclusions In the United States, the degree of overlap between medicinal and recreational cannabis users is 86%. Medicinal and recreational cannabis users favor different modes and amounts of consumption. Only a small proportion (12%) of cannabis users usually consume cannabis and alcohol simultaneously, while concurrent use is common among recreational users. [ABSTRACT FROM AUTHOR]

The article focuses on the use of marijuana as medicine. Topics discussed include the legalization in the U.S. to use medical marijuana, advanced practice registered nurses (APRNs) and legal and regulatory aspects of medical marijuana. Information on Massachusettes Nurse Practice Act which allows nurse practitioners to issue medical marijuana certification is offered.

The authors discuss the use of wastewater-based epidemiology to estimate the size of illicit psychoactive drug markets and evaluate the effectiveness of public health policies which aim to reduce the harm caused by licit and illicit drug use. Topics include a study by Burgard et al which focuses on the use of wastewater-based analysis to monitor the effects of legalized retail sales on cannabis consumption in Washington, and challenges associated with analyzing Tetrahydrocannabinol (THC) levels in wastewater.

The article examines the legalization of cannabis in Washington State. Topics examined include how the legalization is emerging with the reduced criminalization of users, how the legalization, known as Initiative 502 (I-502) passed on November 6, 2012, and the state's focus upon science-based public education and youth-focused prevention.