Nonmedical prescription opioid misuse remains a growing public problem in need of action and is concentrated in areas of US states with large rural populations such as Kentucky, West Virginia, Alaska, and Oklahoma. We developed hypotheses regarding the influence of 4 factors: (1) greater opioid prescription in rural areas, creating availability from which illegal markets can arise; (2) an out-migration of young adults; (3) greater rural social and kinship network connections, which may facilitate drug diversion and distribution; and (4) economic stressors that may create vulnerability to drug use more generally. A systematic consideration of the contexts that create differences in availability, access, and preferences is critical to understanding how drug use context varies across geography.

Background Marijuana is the most frequently used illicit substance in the United States. Little is known of the role that macro-level factors, including community norms and laws related to substance use, play in determining marijuana use, abuse and dependence. We tested the relationship between state-level legalization of medical marijuana and marijuana use, abuse, and dependence. Methods We used the second wave of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a national survey of adults aged 18+ (n=34,653). Selected analyses were replicated using the National Survey on Drug Use and Health (NSDUH), a yearly survey of ~68,000 individuals aged 12+. We measured past-year cannabis use and DSM-IV abuse/dependence. Results In NESARC, residents of states with medical marijuana laws had higher odds of marijuana use (OR: 1.92; 95% CI: 1.49-2.47) and marijuana abuse/dependence (OR: 1.81; 95% CI: 1.22-2.67) than residents of states without such laws. Marijuana abuse/dependence was not more prevalent among marijuana users in these states (OR: 1.03; 95% CI: 0.67-1.60), suggesting that the higher risk for marijuana abuse/dependence in these states was accounted for by higher rates of use. In NSDUH, states that legalized medical marijuana also had higher rates of marijuana use. Conclusions States that legalized medical marijuana had higher rates of marijuana use. Future research needs to examine whether the association is causal, or is due to an underlying common cause, such as community norms supportive of the legalization of medical marijuana and of marijuana use.

IMPORTANCE Historical shifts are occurring in marijuana policy. The effect of legalizing marijuana for recreational use on rates of adolescent marijuana use is a topic of considerable debate.OBJECTIVE To examine the association between the legalization of recreational marijuana use in Washington and Colorado in 2012 and the subsequent perceived harmfulness and use of marijuana by adolescents. DESIGN, SETTING, AND PARTICIPANTSWe used data of 253 902 students in eighth, 10th, and 12th grades from 2010 to 2015 from Monitoring the Future, a national, annual, cross-sectional survey of students in secondary schools in the contiguous United States. Difference-indifference estimates compared changes in perceived harmfulness of marijuana use and in past-month marijuana use in Washington and Colorado prior to recreational marijuana legalization (2010-2012) with postlegalization (2013-2015) vs the contemporaneous trends in other states that did not legalize recreational marijuana use in this period. MAIN OUTCOMES AND MEASURESPerceived harmfulness of marijuana use (great or moderate risk to health from smoking marijuana occasionally) and marijuana use (past 30 days). RESULTSOf the 253 902 participants, 120 590 of 245 065(49.2%) were male, and the mean (SD) age was 15.6 (1.7) years. In Washington, perceived harmfulness declined 14.2% and 16.1% among eighth and 10th graders, respectively, while marijuana use increased 2.0% and 4.1% from 2010-2012 to 2013-2015. In contrast, among states that did not legalize recreational marijuana use, perceived harmfulness decreased by 4.9% and 7.2% among eighth and 10th graders, respectively, and marijuana use decreased by 1.3% and 0.9% over the same period. Difference-in-difference estimates comparing Washington vs states that did not legalize recreational drug use indicated that these differences were significant for perceived harmfulness (eighth

IMPORTANCELittle is known about changes in marijuana use and cannabis use disorder (CUD) after recreational marijuana legalization (RML).OBJECTIVES To examine the associations between RML enactment and changes in marijuana use, frequent use, and CUD in the United States from 2008 to 2016. DESIGN, SETTING, AND PARTICIPANTSThis survey study used repeated cross-sectional survey data from the National Survey on Drug Use and Health (2008-2016) conducted in the United States among participants in the age groups of 12 to 17, 18 to 25, and 26 years or older.INTERVENTIONS Multilevel logistic regression models were fit to obtain estimates of before-vs-after changes in marijuana use among respondents in states enacting RML compared to changes in other states.MAIN OUTCOMES AND MEASURES Self-reported past-month marijuana use, past-month frequent marijuana use, past-month frequent use among past-month users, past-year CUD, and past-year CUD among past-year users. RESULTSThe study included 505 796 respondents consisting of 51.51% females and 77.24% participants 26 years or older. Among the total, 65.43% were white, 11.90% black, 15.36% Hispanic, and 7.31% of other race/ethnicity. Among respondents aged 12 to 17 years, past-year CUD increased from 2.18% to 2.72% after RML enactment, a 25% higher increase than that for the same age group in states that did not enact RML (odds ratio [OR], 1.25; 95% CI, 1.01-1.55). Among past-year marijuana users in this age group, CUD increased from 22.80% to 27.20% (OR, 1.27; 95% CI, 1.01-1.59). Unmeasured confounders would need to be more prevalent in RML states and increase the risk of cannabis use by 1.08 to 1.11 times to explain observed results, indicating results that are sensitive to omitted variables. No associations were found among the respondents aged 18 to 25 years. Among respondents 26 years or older, past-month marijuana use after RML enactment increased from 5.65% to 7.10% (OR, 1.28; 95% CI, 1.16-1.40), past-month frequent use from 2.13% to 2.62% (OR, 1.24; 95% CI, 1.08-1.41), and past-year CUD from 0.90% to 1.23% (OR, 1.36; 95% CI, 1.08-1.71); these results were more robust to unmeasured confounding. Among marijuana users in this age group, past-month frequent marijuana use and past-year CUD did not increase after RML enactment.CONCLUSIONS AND RELEVANCE This study's findings suggest that although marijuana legalization advanced social justice goals, the small post-RML increase in risk for CUD among respondents aged 12 to 17 years and increased frequent use and CUD among adults 26 years or older in this study are a potential public health concern. To undertake prevention efforts, further studies are warranted to assess how these increases occur and to identify subpopulations that may be especially vulnerable.

Medical marijuana laws appear to have contributed to increased prevalence of illicit cannabis use and cannabis use disorders. State-specific policy changes may also have played a role. While medical marijuana may help some, cannabis-related health consequences associated with changes in state marijuana laws should receive consideration by health care professionals and the public.

Background Psychological stress is a proposed risk factor for cardiovascular disease (CVD), and posttraumatic stress disorder (PTSD), the sentinel stress-related mental disorder, occurs twice as frequently in women as men. However, whether PTSD contributes to CVD risk in women is not established. Methods and Results We examined trauma exposure and PTSD symptoms in relation to incident CVD over a 20-year period in 49,978 women in the Nurses’ Health Study II. Proportional hazards models estimated hazard ratios (HRs) and 95% confidence intervals (CIs) for CVD events confirmed by additional information or medical record review [n=548, including myocardial infarction (n=277) and stroke (n=271)]. Trauma exposure and PTSD symptoms were assessed using the Brief Trauma Questionnaire and a PTSD screen. Compared to no trauma exposure, endorsing 4 or more PTSD symptoms was associated with increased CVD risk after adjusting for age, family history, and childhood factors (HR=1.60 [95% CI, 1.20–2.13]). Being trauma-exposed and endorsing no PTSD symptoms was associated with elevated CVD risk (HR=1.45 [95% CI, 1.15–1.83]), although being trauma-exposed and endorsing 1–3 PTSD symptoms was not. After adjusting for adult health behaviors and medical risk factors, this pattern of findings was maintained. Health behaviors and medical risk factors accounted for 14% of the trauma/no symptoms-CVD association and 47% of the trauma/4+ symptoms-CVD association. Conclusion Trauma exposure and elevated PTSD symptoms may increase risk of CVD in this population of women. These findings suggest screening for CVD risk and reducing health risk behaviors in trauma-exposed women may be promising avenues for prevention and intervention.

Background Adolescent marijuana use is associated with adverse later-life consequences, so identifying factors underlying adolescent use is of substantial public health importance. The relationship of U.S. state medical marijuana laws (MML) to adolescent marijuana use has been controversial. Such laws could convey a message about marijuana acceptability that increases marijuana use soon after passage, even if implementation is delayed or the law narrowly limits use. We used 24 years of U.S. national data to examine the relationship between state MML and adolescent marijuana use. Methods Data came from 1,098,270 U.S. adolescents in 8th, 10th, and 12th grade in the national Monitoring the Future annual surveys conducted between 1991–2014. The main outcome was any marijuana use in the prior 30 days. Using multilevel regression modeling, we examined marijuana use in adolescents nested within states, including whether marijuana use was higher overall in states that ever passed a MML up to 2014, and whether the risk of use changed after state MML were passed. Individual-, school- and state-level covariates were controlled. Findings Overall, marijuana use was more prevalent in states that enacted MML up to 2014 than in other states (AOR=1.27, 95%CI=1.07–1.51). Pre- and post-MML risk did not differ in the full sample (AOR=0.92, 95%CI=0.82–1.04). A significant interaction (p<0.001) indicated differential post-MML risk by grade. In 8th graders, post-MML use decreased (AOR=0.73, 95%CI=0.63–0.84), while no significant change occurred in 10th or 12th graders. Results were generally robust across sensitivity analyses. Interpretation Previous evidence and this study show that MML passage does not result in increased adolescent marijuana use. However, overall, adolescent use is higher in states that ever enacted MML than in other states. State-level risk factors other than MML may contribute to both marijuana use and MML, warranting investigation. An observed 8th-grade post-MML decrease also merits further study. Funding U.S. National Institute on Drug Abuse, Columbia University Mailman School of Public Health, New York State Psychiatric Institute.

The urban environment may have a substantial impact on whether an older adult with a given level of functional impairment is able to age actively and remain independent.