Using electronic health record data, we aimed to: Determine the risk of ED and inpatient visits each year from 2010 to 2014 for MUD patients relative to controls; Examine differences in the rates of emergency department and inpatient utilization between MUD patients and controls over 5- years; and Identify predictors of emergency department and inpatient utilization over time within the MUD sample.Marijuana increasingly takes center stage in public policy and debate as legislation to legalize marijuana spreads and use for medical purposes is already established in many states . Attitudes towards liberalization are normalizing, particularly among youth , with regular users at high risk of addiction and developing MUD in adulthood . Consequently, patterns of marijuana use and MUD are rapidly changing and have considerable implications for health systems. This study examined how adult patients with MUD use ED and inpatient resources over time, services that suggest poor health and/or inappropriate use of health care. Findings suggest MUD patients remained at higher risk for having ED and inpatient hospital visits than controls, even though their use of these services declined at a faster rate over the study follow-up period. Further, for MUD patients with cooccurring conditions, utilization of ED and inpatient services continued to increase throughout the follow-up, suggesting these patients may need identification and intervention to address health problems before they become acute. Similar to other studies with different designs and populations , we found that MUD patients had high levels of concurrent medical, psychiatric and substance use disorders. Because these conditions worsen prognosis, lead to high morbidity, commercial weed and contribute to inappropriate service use , it is not surprising we found that MUD patients had consistently greater likelihood of hospital and ED use relative to controls.
In contrast, one recent study reported no association between any marijuana use and patients’ hospital or ED admission status, but this sample consisted of adults who did not have significant medical comorbidity and the study identified frequent use, but not MUD . This difference may reflect the higher severity of patients in our sample, who likely have greater impact on health system resources. Although not specific to MUD, the broader evidence base suggests high ED and hospital utilization among those with substance use disorders is associated with poor health, accidents, and concurrent use of multiple substances , signaling unmet service needs in specialty care, such as addiction treatment and psychiatric care. Further, as legalization evolves and the availability of marijuana increases, there is heightened concern that MUD prevalence and associated health problems will increase . Consequently, building on initial work in this area, it will be critical for future studies to explore the efficacy and feasibility of enhanced screening and intervention for marijuana use and MUD in ED and inpatient settings. Over time all patients had fewer visits, but patients with MUDs experienced a more rapid decrease of visits compared to controls, though MUD patients still maintained higher use at each time point. National data have showed increasing ED visits involving marijuana use . This national increase could be due to the combined effects of increasing marijuana potency, liberalizing views of the drug, and increasing trends toward its legalization . However, our finding of a decrease in ED or inpatient utilization over time may suggest that some patients’ health may improve , and/or may be specific to patients receiving services within integrated health systems where specialty services are provided internally. While we cannot measure this with the current data, it is possible that MUD patients may be more likely to be linked with addiction treatment and other specialty services, as well as primary care services, following an inpatient or ED encounter, potentially reducing the need for subsequent acute care. There are condition- and specialty specific clinical decision support tools embedded in the EHR to assist hospitalists and ED care teams in linking patients back to both primary and secondary care.
For example, during an ED encounter patients can be booked into a follow-up primary care appointment. Prior studies in KPNC have shown patients who have ongoing primary care and addiction treatment are less likely to have subsequent ED visits and inpatient admissions, and this may be related to improved substance use and health outcomes . Despite decreasing utilization rates, it is critical to note that MUD patients were at higher risk of using these services over the follow-up compared to controls, with twice the risk even at the last time point. Thus, MUD patients remain at high risk for ED and inpatient visits despite a more rapid decrease in utilization over time. The health impacts of marijuana use remain controversial as policies evolve, yet our findings indicate that patients with MUD do have more severe health conditions. Co-occurring psychiatric and other substance use disorders and medical conditions were associated with higher odds of ED and inpatient utilization. Each of these comorbidities is over represented among patients who have frequent and inappropriate use of health care services . Most of the related research has focused on patients with alcohol or opioid use disorder, and our findings extend the literature to those with MUD. Patients with MUD are likely to have frequent ED and inpatient visits requiring a range of medical treatments, psychiatric symptom stabilization or detoxification from other drugs or alcohol. This suggests that MUD patients’ presenting problem may not be their only or most severe problem, and clinicians should routinely assess and address multiple cooccurring conditions in these individuals. Several limitations should be noted. We relied on provider-assigned clinical diagnoses, which limited the sample to patients who had a MUD disorder diagnosis and a health care visit, which may represent the lower bound of identified MUD, though we did include current and preexisting diagnoses. We did not have data on rate or frequency of marijuana use; it is important to examine outcomes related to the extent and severity of marijuana related problems in future prospective studies. We did not have data on the reason for ED or hospital admission or length of stay, which are important areas of further investigation.
ED utilization that Kaiser did not pay for is not captured. Patients were insured members of an integrated health system, and the results may not be generalizable to uninsured populations or to other types of health plans. As noted previously, patients were required to have a health plan visit in 2010 for cohort selection, but were not required to have a health plan visit in subsequent years, which may partially explain the steep decline in ED and inpatient hospitalization visits between 2010 and 2011 and the subsequent leveling off of ED use from 2011 to 2014. However, patients were required to have membership four of the five years, and visits continued to decline over the study period; utilization for MUD patients were consistently higher than non-MUD patients. This study found that MUD patients remained at high risk for having ED and inpatient visits, even though utilization of these services significantly declined over 5-years. Utilization of ED and inpatient services was higher for MUD patients with co-occurring conditions throughout the follow-up, suggesting that targeting these patients for outreach and intervention may be a useful strategy for improving outcomes.Over the past decade, there has been a notable change in the consumption patterns of inhaled and ingested substances, driven in part by the increased legalization of cannabis and the growing popularity of electronic cigarettes . While cigarette use is on the decline, the use of e-cigarettes and marijuana has witnessed an upward trend, which is expected to continue with the ongoing progress of cannabis legalization across states and diminishing societal stigma. Despite these changes, there remains limited research on the frequency of use, effectiveness, and safety of these substances for various medical conditions, particularly among individuals with underlying lung disease. Cystic fibrosis , formerly considered a fatal condition, has experienced a remarkable transformation, drying rack for cannabis largely attributed to advances in precision medicine and the introduction of modulator therapy. As the CF population continues to age, attention is shifting towards addressing unique challenges teenagers and adults face, including mental health and substance use. People with CF may seek complementary and alternative treatments to address common issues associated with their chronic illness, including treatment burden, anxiety, depression, decreased appetite, pain, and sleep disturbances.
Additionally, as health outcomes improve in the era of effective modulator therapy and respiratory symptoms become less prominent, pwCF may resort to inhalation of substances that could have significant impact on their lung health. Limited data currently exists on the prevalence, modalities, perceptions, demographic, and health factors associated with using marijuana, cannabidiol , e-cigarettes, and cigarettes in pwCF, particularly in the era of effective modulator therapy. In the past decade, there were only two studies on substance abuse in CF ; both were conducted before the legalization of marijuana and before the majority of pwCF qualifying for effective modulator therapy. Given these evolving circumstances, it is essential to reexamine substance use and its perception among pwCF. Gaining a deeper understanding of substance usage patterns can enhance the quality of clinical care and provide valuable insights into the underlying reasons, empowering healthcare teams to provide informed guidance and support. In this study, we investigated the rate of use of marijuana, CBD, e-cigarette, and cigarettes within the CF community and the characteristics of users. We sought to determine if pwCFusing these substances were on cystic fibrosis transmembrane receptor modulators as well. Lastly, we investigated reasons for and attitudes regarding substance usage and self-reported clinical outcomes with substance use. Recent users were compared to nonusers of each substance for all analyses. To assess differences in socioeconomic characteristics, demographics, and illness severity markers, Fishers exact test was used. Univariate and multivariate logistic regressions were performed to evaluate the unadjusted and adjusted association between usage of CFTR modulators and recent usage of each substance. Potential confounders included in the multivariate models were chosen a priori based on prior literature and a directed acyclic graph of the framework of potential relationships of use of CFTR modulators and substance use. Potential confounders were gender , age , race and ethnicity , FEV1 percent predicted , PHQ-4 . Subjects with missing data were excluded from the regression analyses. A p value of less than .05 was considered statistically significant. All statistical analyses were conducted using R version 4.2.1 . The study procedures were reviewed and approved by the Institutional Review Board at the University of California, San Francisco .Overall, we found that recent users of each of the four substances were more likely to be college-educated, between the ages of 26 and 39 years old, and Black when compared to nonusers. Demographic and socioeconomic characteristics between recent users and nonusers differ depending on the substance used . Compared to nonusers, recent users of CBD, e-cigarettes, and cigarettes were more likely to be male, which contrasts with recent marijuana users, who were slightly more likely to identify as female and other gender identities. Black subjects were more likely to be recent users of all substances than other races. Non-Hispanic white subjects were more likely to be recent users of marijuana and cigarettes. Asian, Native American, other races, or multirace subjects were more likely to be recent users of e-cigarettes. It is worth noting that while we did appreciate significance when comparing race/ethnicity to recent substance use, representation of non-White participants was limited, potentially limiting the generalizability of the findings. Specific to marijuana, there was no significant association between recent users and nonusers and state of residence in terms of legality based on cannabis laws during the study period. However among recent users, there was a higher percentage of use in states where marijuana was legalized , compared to those in medically legal and illegal states . Significant patterns also emerged with respect to markers of CF disease severity and PHQ-4 scores between recent users and nonusers . Recent marijuana users were more likely to be on pancreatic enzymes, while recent cigarette users were less likely to be on pancreatic enzymes. Subjects with self-reported FEV1 percent predicted of 60%–80% were more likely to be recent users of e-cigarettes and cigarettes as compared to nonusers who were more likely to have a self-reported FEV1 less than 60% and greater than 80%.