Abstract
State cannabis laws are changing rapidly. Research is inconclusive about their association with rates of self-harm and assault. Existing studies have not considered variations in cannabis commercialization across states over time. To evaluate the association of state medical and recreational cannabis laws with self-harm and assault, overall and by age and sex, while considering varying degrees of commercialization. Using a cohort design with panel fixed-effects analysis, within-state changes in claims for self-harm and assault injuries before and after changes in cannabis laws were quantified in all 50 US states and the District of Columbia. Comprehensive claims data on commercial and Medicare Advantage health plan beneficiaries from January 1, 2003, to December 31, 2017, grouped by state and month, were evaluated. Data analysis was conducted from January 31, 2020, to January 21, 2021. Categorical variable that indexed the degree of cannabis legalization in each state and month based on law type (medical or recreational) and operational status of dispensaries (commercialization). Claims for self-harm and assault injuries based on International Classification of Diseases codes. The analysis included 75 395 344 beneficiaries (mean [SD] age, 47 [22] years; 50% female; and median follow-up, 17 months [interquartile range, 8-36 months]). During the study period, 29 states permitted use of medical cannabis and 11 permitted recreational cannabis. Point estimates for populationwide rates of self-harm and assault injuries were higher in states legalizing recreational cannabis compared with states with no cannabis laws, but these results were not statistically significant (adjusted rate ratio [aRR] assault, recreational dispensaries: 1.27; 95% CI, 0.79-2.03;self-harm, recreational dispensaries aRR: 1.15; 95% CI, 0.89-1.50). Results varied by age and sex with no associations found except for states with recreational policies and self-harm among males younger than 40 years (aRR <21 years, recreational without dispensaries: 1.70; 95% CI, 1.11-2.61; aRR aged 21-39 years, recreational dispensaries: 1.46; 95% CI, 1.01-2.12). Medical cannabis was generally not associated with self-harm or assault injuries populationwide or among age and sex subgroups. Recreational cannabis legalization appears to be associated with relative increases in rates of claims for self-harm among male health plan beneficiaries younger than 40 years. There was no association between cannabis legalization and self-harm or assault, for any other age and sex group or for medical cannabis. States that legalize but still constrain commercialization may be better positioned to protect younger male populations from unintended harms.
Highlights
Cannabis laws may be underappreciated factors for the rates of self-harm and assault,[1,2,3] the second and fifth leading causes of death among individuals aged 15 to 49 years in the US, respectively.[4]
Point estimates for populationwide rates of self-harm and assault injuries were higher in states legalizing recreational cannabis compared with states with no cannabis laws, but these results were not statistically significant
Recreational cannabis legalization appears to be associated with relative increases in rates of claims for self-harm among male health plan beneficiaries younger than 40 years
Summary
Cannabis laws may be underappreciated factors for the rates of self-harm and assault,[1,2,3] the second and fifth leading causes of death among individuals aged 15 to 49 years in the US, respectively.[4]. Increases in the availability of cannabis products are likely to increase cannabis use, including heavy use.[5,6,7,8,9] Cannabis intoxication can lead to behavioral disinhibition, altered perceptions and judgment, impaired memory, and elevated physiologic arousal, including paranoia These factors can heighten violence proclivity and increase vulnerability to violence.[10,11,12,13,14,15] Regular and heavy use of increasingly highpotency cannabis products[16,17] have been linked to risk factors for self-harm and assault injury, including impaired cognitive function, concomitant alcohol use, psychosis, depressive disorders, and suicidal ideation and attempts.[10,18] Meta-analyses of data on youth, intimate partners, and individuals with serious mental disorders, as well as animal and brain imaging studies, link high tetrahydrocannabinol (THC) doses to aggression and violence perpetration.[15] cannabis dispensaries, like liquor stores, could attract crime in immediately surrounding areas,[18,19,20] some have proposed that cannabis legalization could reduce violence by replacing illegal markets and reducing alcohol consumption.[21]
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