It is important that consumers receive accurate information on whether or not a product is organic. The European Union prohibits the use of “organic” on any product label where less than 95% by weight of ingredients of agricultural origin are not organic, or any product produced with or containing genetically-modified organisms. Similar provisions are included in US product labeling law. Due to federal prohibition of marijuana in the United States, however, marijuana companies are not allowed to market marijuana products as ‘organic’. If federal prohibition is lifted, companies may use the term ‘organic’ in marijuana packaging and marketing to increase product appeal. More research is needed to understand how organic labeling on marijuana packages impacts risk perceptions and use, and what public health messages could counteract misperceptions of risk. Young adults may be receptive to health-related content on tobacco warnings and this could be translated to warning labels for hookah, e-cigarettes, and marijuana. While these findings should be validated with a larger sample, for many participants chemicals, toxins, and additives were associated with greater harm. Warnings for hookah, e-cigarettes, and marijuana could address chemicals and toxins found in the organic matter, as well as chemicals used to produce marijuana concentrates and e-liquids. Warning labels could address the misperception that a product is safer because it contains, or was extracted with, water. Warning labels reflecting the novel themes identified in this study might be more effective if they follow the current state of the art for tobacco warning labels, including use of images in addition to text,ebb flow tray and if warning label messages are reinforced by mass media educational campaigns. The opioid epidemic is a major public health concern in the United States . The number of opioids prescribed in 2015 was approximately three times as high as in 1999 . At least 11.8 million adolescents and adults misused opioids, and 2.1 million had an opioid use disorder , in 2016 . The opioid-related hospitalizations increased by 64%, and emergency department visits doubled, in 2005-2014 .
Over the past decade, concerted policy efforts have been made to restrict the prescribing of opioids . Expanding access to effective treatments for OUD is essential to reduce its burden . Historically, medications for treating OUD, such as methadone and buprenorphine, were provided only in opioid treatment programs, and, therefore, only a fraction of patients were willing and able to access these medications . To expand the clinical ability to treat OUD, the US Drug Addiction Treatment Act of 2000 waived the requirement of obtaining a Drug Enforcement Administration registration as an opioid treatment program for physicians providing buprenorphine treatment in their offices. Physicians can acquire DATA-2000 waivers if they had a board certification in addiction medicine or psychiatry or completed required training . Since 2010, there has been a dramatic increase in the number of DATA-2000 waivered providers . These providers might be more likely to begin prescribing buprenorphine in areas with higher opioid-related mortality rates . It was hoped that expanding the capacity of buprenorphine treatment could improve access to OUD treatment. The expansion of buprenorphine treatment affected opioid-related outcomes at the population level has remained unexplored. Parallel with the opioid epidemic, marijuana legalization has expanded throughout the US. As of November 2018, in addition to the District of Columbia, 33 states have legalized marijuana use for medical purposes, 10 of which further legalized marijuana use for recreational purposes. First, marijuana use may exacerbate opioid use. Second, marijuana use may substitute for opioid use . The rationale for the first hypothesis was that marijuana may precede use of opioids, and individuals who used marijuana may share risk factors with individuals who used opioids . As demonstrated by a cohort study, recreational marijuana use was associated with increased likelihoods of opioid misuse and OUD . But the data of this study were collected before any states have legalized recreational marijuana use.
The evidence on the impact of state recreational marijuana laws on opioid-related outcomes remained scarce, and no positive associations have been documented . The rationale for the second hypothesis was the potential therapeutic effects of cannabinoids and smoked marijuana on pain symptoms, which were supported bysystematic reviews of randomized controlled trials . Chronic or severe pain was, therefore, the most commonly approved condition in the states that legalized medical marijuana. Several ecological studies consistently suggested that state-wide medical marijuana laws were associated with considerable reductions in opioid prescriptions, misuse, overdose deaths, and related hospitalizations at state level . However, these ecological studies above were not supported by a recent individual-level prospective cohort study in Australia which found no evidence that marijuana use was associated with reduced opioid use among pain patients . But in this study, the majority of participants used illicitly obtained marijuana. It is still unknown to what extent the findings can be generalized to the current legal environment in the US. The availability of marijuana dispensaries and DATA-2000 waivered providers varied substantially across neighborhoods within a state, but its associations with opioid-related outcomes in a neighborhood was unknown . To fill the knowledge gap, we examined the associations of neighborhood availability of marijuana dispensaries and DATA-2000 waivered providers with hospital stays related to opioids, using hospital records from January through June in 2016 in Washington. We hypothesized that the availability of recreational and medical marijuana dispensaries was associated with a higher and lower risk of hospital stays related to opioids, respectively. According to availability theory, increased access to marijuana may lead to increased marijuana use among the local population .
Thus, increased availability of recreational marijuana dispensaries may result in increased marijuana use for recreational purposes which may lead to increased opioid or OUD-related health outcomes, while increased availability of medical marijuana dispensaries may results in elevated marijuana use for medical purposes which may lead to alleviated opioid or OUD-related health outcomes. We also hypothesized that the availability of DATA-2000 waivered providers was associated with a lower risk of hospital stays related to opioids. According to the Andersen’s behavioral model of health services use, individuals living in areas with more available health care resources were more likely to visit a provider . One study reported that living in neighborhoods with more DATA-2000 waivered providers was associated with an increased likelihood of being treated with buprenorphine for OUD . Thus, increased availability of DATA-2000 waivered providers may lead to improved opioid- or OUD-related health comes through more accessible OUD treatment. To analyze the potential differential associations with recreational and medical marijuana dispensaries,flood and drain tray we took advantage of the unique policy context in Washington in early 2016, a time when recreational marijuana and medical marijuana dispensaries coexisted. Washington passed the laws to legalize medical marijuana in 1998 and recreational marijuana in 2012. Before recreational marijuana was legalized, medical marijuana dispensaries in Washington largely operated without regulations. Unlike other states such as Colorado that built its recreational marijuana industry and regulations on top of the existing medical marijuana system, Washington chose to abandon its medical marijuana system and start recreational marijuana regulations from scratch. In 2015, Washington passed the Cannabis Patient Protection Act requiring that all marijuana dispensaries operate as licensed recreational marijuana dispensaries and obtain a medical marijuana endorsement if they opt to specialize in medical marijuana . As a result, between July 2014 when the first recreational marijuana dispensary opened and July 2016 when SB 5052 took effect, the old medical marijuana dispensaries that exclusively served medical marijuana patients and the newly licensed recreational marijuana dispensaries that might serve both patients and recreational users operated at the same time in Washington. This is a cross-sectional ecological study using secondary de-identified data, and the ethics approval and consent were not needed.
We obtained inpatient and observation stay discharge records in all the community hospitals between January 1, 2016 and June 30, 2016 from Washington Comprehensive Hospital Abstract Reporting System administered by the State Department of Health. The records included detailed information on patient demographics, zip code of patient’s home address, as well as up to 25 International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis and procedure codes. Patients younger than 12 years of age or living outside of Washington were excluded from the analyses. The final study sample included 264,013 inpatient stay records and 12,621 observation stay records. Directories and point locations of marijuana dispensaries with physical storefronts in Washington were obtained between March and June in 2016 from a crowd sourced website . Weedmaps provides detailed and up-to-date dispensary information contributed by dispensary owners and users. Its data have been validated and used in previous research . Notably, each dispensary on weedmaps self reports whether it is a medical or recreational marijuana dispensary. This is the only source to differentiate recreational and medical marijuana dispensaries during our study period, as official records for medical marijuana dispensaries were not available until they were regulated in July 2016. Directories and point locations of DATA-2000 waivered providers in Washington were obtained in August 2016 from the Substance Abuse and Mental Health Services Administration. Tobacco and alcohol outlet locations were obtained from business list provider reference USA and other contextual factors were obtained from the US Census and the American Community Survey.The patient-level outcome variables were opioid related hospital stays, including inpatient stays and observation stays. Inpatient stays were hospital stays after patients were formally admitted to a hospital. Observation stays were short-term hospital stays for patients who were not well enough to go home but not sick enough to be admitted right away. Observation stays usually lasted for less than 24 hours and rarely exceeded 48 hours. Patients were either discharged or admitted as inpatients after observation stays. In CHARS, if a patient was transferred to inpatient care after an observation stay, this patient would only be recorded as an inpatient. In other words, observation stay discharge records in CHARS captured patients who were discharged after observation stays. To construct opioid-related hospital stays, we first used ICD-10-CM diagnosis codes to identify OUD and opioid overdose . A hospital stay with OUD or opioid overdose in all-listed diagnoses, including principal diagnoses as well as secondary diagnoses, was defined as an opioid-related hospital stay. Accordingly, three dichotomized indicators were created to represent inpatient stays involved with OUD, inpatient stays involved with opioid overdose, and observation stays involved with OUD. Observation stays involved with opioid overdose were not analyzed because of insufficient sample size. The primary explanatory variables of interest were the availability of marijuana dispensaries and DATA-2000 waivered providers in a neighborhood defined by zip code tabulation area . Measures for recreational and medical marijuana dispensaries were constructed separately. All the point locations were geocoded using ArcGIS and aggregated to zip code level. Availability was measured by the density of marijuana dispensaries or DATA-2000 waivered providers per square mile. In sensitivity analyses, we altered the operationalization of primary explanatory variables to test the robustness of our results. First, we used the total density of recreational and medical marijuana dispensaries. Second, we used three dichotomous variables indicating the presence of any recreational marijuana dispensaries, medical marijuana dispensaries, or DATA-2000 waivered providers because the majority of zip codes did not have any of them. Third, we used three categorical variables to represent 0, 1, and 2+ recreational marijuana dispensaries, medical marijuana dispensaries, or DATA-2000 waivered providers in a zip code, as few zip codes had more than two of them. Patient-level covariates included age , sex , primary payer , and race/ethnicity . Zip code level covariates included proportion of population under age 21 , whether the population were predominantly racial and ethnic minority , median household income in thousand dollars of 2016, number of tobacco and alcohol outlets per square mile, and population density . The descriptive and regression analyses were conducted in STATA 14 . We conducted multilevel logistic regressions with random intercepts at the zip code level to examine the associations of the availability of DATA-2000 waivered providers and marijuana dispensaries with opioid-related inpatient or observation stays, controlling for other patient and neighborhood covariates. Multilevel models were used to account for within-neighborhood correlations, as patients nested within zip codes shared the same zip code level explanatory variables of interest and covariates.