Objectives. To investigate the effects of recreational cannabis laws (RCLs) on the rate of Medicare fee-for-service enrollees with cannabis-related disorders (CRDs) and claims involving CRDs.

Methods. We used Medicare fee-for-service inpatient and outpatient claims from 2010 to 2022 to compare CRD outcomes in US states with and without effective RCLs and open recreational cannabis dispensaries (RCDs) using difference-in-difference models. We estimated the impact of RCLs and RCDs on the overall rate of Medicare enrollees with CRD per 10 000 enrollees and the rate of claims with CRD per 10 000 enrollees at the state‒year level (n = 663).

Results. We found statistically significant increases in CRD outcomes following RCLs (19.73 patients per 10 000 enrollees [P < .001]; 20.56 claims per 10 000 enrollees [P = .005]) and RCDs (14.14 patients per 10 000 enrollees [P < .001]; 13.98 claims per 10 000 enrollees [P = .004]).

Conclusions. Given that RCLs were associated with increased rates of CRD diagnoses and claims including CRD among Medicare fee-for-service enrollees, states considering implementation of RCLs should consider the negative harms of legalization, particularly for older adults. 

Why does this matter?

Increases in opioid exposures during the COVID‐19 pandemic highlight the importance of providing medication administration support for older adults aged 65 and older as well as the importance of caregiving and appropriate opioid prescribing.

• This interrupted time series analysis examined opioid exposures among adults aged 55 and older whose exposures were reported to any U.S. Poison Centers from 2016 to 2021.

• Results showed significant increases in opioid exposures for licit formulations of opioids among Americans aged 65 and older following the onset of the COVID‐19 pandemic.

• Increases in opioid exposures were primarily related to medication errors among Americans aged 65 and older.

Keywords: COVID‐19 pandemic, older adults, opioid exposure

Key Points

Question  Is cannabis availability through medical or recreational cannabis dispensary openings associated with opioid prescription use among commercially insured patients diagnosed with cancer in the US?

Findings  In this repeated cross-sectional study following a mean of 3.05 million patients annually, significant reductions were found in the rate of patients with cancer with opioid prescriptions, the mean daily supply, and the mean number of prescriptions per patient after medical and recreational cannabis dispensary openings.

Meaning  These findings indicate that medical or recreational cannabis laws may be significantly associated with reduced opioid use among patients diagnosed with cancer.

Background There is limited evidence from systematic nationwide studies evaluating the impact of cannabis legalization on cannabis-related exposures among the pediatric population. Using the National Poison Data System (NPDS), we calculated the effects of medical and recreational cannabis dispensaries on reported pediatric cannabis exposures.

Methods We analyzed data from 36,161 reported cannabis-related exposures for individuals aged 2–20 between 2016 and 2021, comparing states with and without open medical cannabis dispensaries and states with open recreational cannabis dispensaries to states with open medical cannabis dispensaries. Using a difference-in-difference design, we estimated the effects of cannabis dispensary openings on semi-annual cannabis exposures by age group: young children (2–6 years old), children (7–11), adolescents (12–17), and young adults (18–20).

Results Patients aged 2–6 (96.3%) and 7–11 (82.4%) frequently incurred unintentional exposures, while patients aged 12–17 (79.9%) and 18–20 (77.5%) more often incurred intentional exposures. Medical cannabis dispensary openings were associated with a 52.3% increase (CI 37.5–67.0; p < .001) in cannabis-related exposure rates in individuals aged 2–6. However, we found a 42.4% decrease (95% CI: −62.2 to −22.6; p < .001) in the number of exposures occurring per 100,000 population when recreational dispensaries opened, relative to states with only medical cannabis dispensaries open. While we did not find statistically significant increases among children aged 7–11 following medical cannabis dispensary openings, we did see a 26.6% (95% CI: −45.1 to −8.1) decrease following recreational cannabis dispensary openings. We did not find statistically significant effects for other age groups.

Conclusions Our findings indicate policymakers may need to invest in providing cannabis safety education when medical cannabis dispensaries open to avoid unintended exposures, though some of that effect appears to be mitigated by the time recreational dispensaries (eventually) open. Professionals that provide medical cannabis or provide care in medical cannabis states should consider providing education about how to safely use and store cannabis in the household to prevent cannabis-involved exposures.

Purpose To determine whether reports of selected opioid exposures reported to America's Poison Centers changed during the COVID-19 pandemic, among adolescents aged 12–17 years.

Methods We analyze all reported opioid exposures (n = 13,174) for adolescents aged 12–17 years in the United States, before and during COVID-19 (January 1, 2016–December 31, 2021). Outcome variables measured the rate of opioid exposures per 100,000 population, stratified by age, opioid type, and reason. We use linear regression to fit the time series for prepandemic outcomes and forecast exposures from March 2020 to December 2021, based on this trend. We compare forecasted and actual values to estimate the association between the pandemic and opioid exposures.

Results Reports of opioid exposure increased by 0.017 reports per 100,000 over the forecasted estimate (forecasted: 0.04 [95% confidence interval: 0.034–0.054], actual: 0.061, difference: 0.017, p < .05), equivalent to a 38.6% increase among adolescents aged 12–17 years. Reports due to intentional exposure and opioid misuse in adolescents aged 12–17 years increased.

Discussion Adolescents were at increased risk of opioid exposure following the COVID-19 pandemic and continue to be at risk despite many aspects of life returning to pre-COVID-19 normalcy.

Objective: Almost half of U.S. states have passed recreational cannabis laws as of May 2024. While considerable evidence to date indicates cannabis may be a substitute for prescription opioids in the treatment of pain, it remains unclear if patients are treating pain with cannabis alone or concomitantly with other medications. 

Method: Using data from a national sample of commercially insured adults, we examine the effect of recreational cannabis legalization (through two sequential policies) on prescribing of opioids, NSAIDS, and other pain medications by implementing synthetic control estimations and constructing case-study level counterfactuals for the years 2007-2020. 

Results: Overall, we find recreational cannabis legalization is associated with a decrease in opioid fills among commercially insured adults in the U.S., and we find evidence of a compositional change in prescriptions of pain medications more broadly. Specifically, we find marginally significant increases in prescribing of non-opioid pain medications after recreational cannabis becomes legal in some states. Once recreational cannabis dispensaries open, we find statistically significant decreases in the rate of opioid prescriptions (13% reduction from baseline, p < .05) and marginally significant decreases in the average daily supply of opioids (6.3% decrease, p < .10) and number of opioid prescriptions per patient (3.5% decrease, p < .10).

Conclusions: These results suggest that substitution of cannabis for traditional pain medications increases as the availability of recreational cannabis increases. There appears to be a small shift once recreational cannabis becomes legal, but we see stronger results once users can purchase cannabis at recreational dispensaries. The decrease in opioids and marginal increase in non-opioid pain medication may reflect patients substituting opioids with cannabis and non-opioid pain medications, either separately or concomitantly. Reductions in opioid prescription fills stemming from recreational cannabis legalization may prevent exposure to opioids in patients with pain and lead to decreases in the number of new opioid users, rates of opioid use disorder, and related harms.

 Objective: Fentanyl contributes heavily to drug overdose deaths in the United States. Fentanyl test strips (FTS) may prevent unintentional fentanyl exposures but were classified as drug paraphernalia and were criminalized in most states until recently. This retrospective analysis examined the association between state policies excluding FTS from the definition of drug paraphernalia (FTS reclassification, or FTSR) and opioid overdose mortality. 

Method: This study used difference-in-differences models accounting for staggered policy adoption to compare the share of opioid-related deaths, and specifically the share of synthetic opioid-related deaths, among all drug-involved deaths in states with and without FTSR between January 2017 and December 2023. Supplementary analyses examined internet searches for FTS following policy changes and use alternative FTS legalization measures. Mortality data were from the U.S. National Vital Statistics System and internet search data came from a restricted application program interface. 

Results: FTSR was associated with a significant 7.5% reduction in the share of drug-related deaths involving opioids [ATT: -0.078; p-value=0.001; 95% CI: -0.144, -0.038]. FTSR was associated with a larger, 17.5% reduction in the share of drug-related deaths involving synthetic opioids [ATT: -0.192; p-value=0.017; 95% CI: -0.349, -0.035]. Supplementary analyses results indicated increases in internet searches for FTS following FTSR and corroborated estimated reductions in drug-related deaths involving opioids. 

Conclusion: FTSR was associated with a reduction in the share of drug-related overdose deaths involving opioids/synthetic opioids, suggesting that that FTS and FTSR may be an important harm reduction tool for people who use drugs.  

Public Health Significance Statement: This research provided evidence that state exclusion of fentanyl test strip (FTS) from the legal definition of drug paraphernalia was associated with reductions in the share of drug-related deaths involving opioids. Results indicated that FTS these policies may help people who use drugs avoid synthetic opioid overdose. These findings provided evidence that policies can help promote effective harm reduction strategies among people who use drugs.  

Objectives: To examine the effects of recreational cannabis laws (RCLs) on emergency department (ED) visits involving cannabis related disorders (CRD) or suspected cannabinoid hyperemesis syndrome (CHS) in the Medicare population. 

Methods: Difference-in-difference analysis was used to analyze Medicare fee-for-service and Medicare Advantage claims from 2016 to 2022, comparing rates of Medicare-covered ED visits involving CRD or CHS in states with and without effective recreational cannabis laws (RCLs) or open recreational cannabis dispensaries (RCDs). 

Results: We found a statistically significant relationship between RCLs and ED visits involving suspected CHS (0.096 visits/10,000 enrollees, p-value=0.039), and a marginally significant relationship between RCDs and ED visits involving suspected CHS (0.066 visits/10,000 enrollees, p-value=0.098). Findings did not show a statistically significant association between RCDs and ED visits involving CRD, but RCLs were associated with marginally significant increases (0.899 visits/10,000 enrollees, p-value=0.061).  

Conclusions: Results indicated increases in CRD- and CHS-related ED visits among Medicare enrollees associated with both RCLs and RCDs, with larger effects estimated following RCLs.  

Policy Implications: Results indicated the need for policies encouraging safe cannabis consumption, including among older adults, following liberalization. 

Importance: Substance use disorder (SUD) is rising among pregnant women in recent years and drug overdose deaths contribute to increased mortality among pregnant and postpartum women.  

Objective: To examine geographical variation in categorized SUD birth rates in the United States. 

Design: Retrospective repeated cross-sectional analysis. 

Setting: We included all Medicaid claims from 2017-2021.  

Participants: Medicaid enrollees aged 15 to 64 years. Enrollees were included if they gave birth within the study period. 

Exposures: We separately identified Enrollees who were diagnosed with cannabis, opioid, alcohol, cocaine, or other stimulant use disorder prior to giving birth. We identified whether state overall SUD rates were above or below the national average.  

Main Outcomes and Measures: We summed the number of live births in each state annually and for the duration of the study period. We separately summed live births to individuals with each pre-existing SUD. We calculated SUD birth rates per 10,000 live births.  

Results: There is strong state-level variation in state-level SUD birth rates, with some states. Although the cannabis use disorder birth rate was highest nationally, a greater number of states displayed high (>10% of births) opioid and alcohol use disorder birth rates. States without Medicaid Expansion were more likely to display lower rates  

Conclusions and Relevance: We found substantial state heterogeneity in pre-existing SUD birth rates. Our findings suggest that targeted interventions and therapies for various SUDs may be most beneficial to pregnant and postpartum women, and Medicaid expansion may have improved coverage among pregnant enrollees with SUD. 

Importance: Over the past decade, substance use disorder (SUD) among pregnant women has dramatically increased. Given that Medicaid covers roughly 70% of births to individuals with an SUD (SUD births) in the United States, this is a critical population to study. However, prior studies of this population are limited. 

Objective: To examine rates of Medicaid insured births with SUD from 2017 to 2021 and differences in rates by rurality. 

Design, Setting, Participants: In this cross-sectional study of 8,158,505 Medicaid insured births we examined SUD births per 10,000 births. Data on all Medicaid beneficiaries with a live birth between January 1, 2017 and December 31, 2021 were extracted from the Transformed Medicaid Statistical Information System Analytic Files. Analyses were conducted from May 2025 to April 2026. 

Exposures: Year of study period and rurality of beneficiary county of residence. 

Main Outcomes and Measures: The main outcomes were annual Medicaid insured SUD births, including opioid use disorder (OUD), alcohol use disorder (AUD), cannabis use disorder (CUD), cocaine use disorder (CoUD), and other stimulant use disorder (StimUD) per 10,000 live births. 

Results: Our study sample included 769,411 SUD births (mean age: 27.55 years). We found significant increases in rates of Medicaid insured SUD births from 2017 to 2021, with the exception of OUD which declined from 2020 to 2021. The largest increases were observed for Medicaid insured births with CUD (increase of 275.20 births per 10,000, p<.001), followed by AUD (increase of 168.26 births per 10,000, p=0.004) and StimUD (increase of 128.69 births per 10,000, p =0.002). Overall, rates of Medicaid insured births with SUD were higher among beneficiaries living in rural counties compared to urban counties.

Conclusions and Relevance: In this cross-sectional study of rates of Medicaid insured SUD births, we found that rates significantly increased over the study period and were generally higher among beneficiaries residing in rural versus urban counties. Further, rates of Medicaid-insured CUD births increased at an alarming rate over the study period. Overall, our findings highlight the continued need to expand SUD treatment options for pregnant and postpartum populations, with particular attention to rural areas.