The relationship of cannabis decriminalization in Colorado and cannabis use in individuals with alcohol use disorders

Publisher Name: 
Giovanni Williams
Wednesday, April 1, 2020 - 06:00

Objective
Over the past decade, cannabis use has become increasingly popular in states that include Colorado. During this time, alcohol use disorders (AUDs) and alcohol-related medical conditions have also been consistently recognized as public health problems with increasing prevalence in the state. Despite the widespread use of cannabis in Colorado, the epidemiology of cannabis use among those with AUDs has been poorly described. Therefore, we sought to examine cannabis use among individuals with likely AUDs and individuals with low-risk alcohol use during a time of major Colorado legislative changes before and after legalization of recreational cannabis in 2012.

Methods
This study was a secondary data analysis conducted with information from 303 participants (80% male) in the Denver, CO metropolitan enrolled between August 2007 and April 2016 for studies related to alcohol and lung health. Of these participants, 188 (62%) were completing inpatient alcohol detoxification with likely AUDs. All participants completed the Alcohol Use Disorder Identification Test (AUDIT) to establish their likelihood of an AUD, and all had information on current cannabis use assessed by questionnaire and urine toxicology testing.

Results
Individuals with likely AUDs more commonly used cannabis compared to control participants (42% vs 27%, p = 0.007). In multiple logistic regression analyses, participant type (likely AUD versus control), tobacco smoking, and age were significantly associated with cannabis smoking; however, the year of participant enrollment was not. Adjusted odds for cannabis use among participants with likely AUDs were 2.97 (1.51–5.82), p = 0.002, while odds for cannabis use among tobacco smokers were 3.67 (1.94–6.93), p < 0.0001. Among control participants, tobacco smoking increased odds of cannabis use seven-fold.

Conclusions
Our findings highlight the exceptionally high odds of cannabis use among individuals with likely AUDs undergoing alcohol detoxification at a Colorado treatment facility before and after legalization of recreational cannabis. Targeted investigations into the medical and psychiatric consequences of combined alcohol and cannabis use are urgently needed to define its health impact in these vulnerable individuals.

Introduction
As cannabis legislation has rapidly evolved in the United States, cannabis’ acceptability and use have increased steadily. The impact of widespread cannabis availability on its use is particularly important to delineate in individuals with alcohol use disorders (AUDs), who are at-risk for serious mental and medical health conditions, particularly liver disease and pulmonary infections (Caputo et al. 2012; Clark et al. 2013; Fernandez-Sola et al. 1995; Moss and Burnham 2006; Saitz et al. 1997). Although some studies indicating deleterious health outcomes from cannabis use have emerged, the evidence remains sparse (Lee and Hancox 2011; Committee on the Health Effects of Marijuana 2017; Pletcher et al. 2012). Both alcohol (Mayfield et al. 2013; Moss and Burnham 2006) and cannabinoids (Cabral et al. 2015) possess potent immunomodulatory effects, but their combined effects on health are not well understood. Epidemiologic investigations suggest an association between cannabis use and decreased severity of alcohol-related end-organ damage in such diseases as pancreatitis (Goyal et al. 2017) and liver disease (Adejumo et al. 2018). Precise mechanisms underlying protective effects of cannabis in alcohol-related diseases are not established, but the potential ability of cannabis to attenuate pro-inflammatory cytokine production necessary for progression of alcohol-related diseases has been postulated to play a role (Karoly et al. 2018). However, combined use of alcohol and cannabis may negatively impact public health, as dual use has been linked to the development of alcohol dependence (Midanik et al. 2007), increased health care utilization (John and Wu 2017), and an impaired ability to perform motor tasks such as driving (Downey et al. 2013). Compared to other states, Colorado ranks highly in both its use of alcohol and cannabis consumption. Data collected during 2013–2014 revealed that over 60% of adults reported alcohol consumption within the past month, and 6.9% were diagnosed with alcohol abuse or dependence (SAMHSA 2014) based on Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV definitions. During this same period, cannabis use was reported in 16.80% of Colorado adults older than 26 years in the prior year, an increase from 10.73% in 2003 (SAMHSA 2014). Whether cannabis use in Colorado serves as a substitute or complement to alcohol use is unclear; results from published investigations involving US populations are conflicted (Subbaraman 2016), and may be related to characteristics of the study populations. For example, in recently sober patients with AUDs, continued cannabis use was associated with fewer days of alcohol abstinence (Subbaraman et al. 2017), while use of cannabis for medical indications has been linked to less problem