Prenatal substance use policies and newborn health.

We study the effect of punitive and priority treatment policies relating to illicit substance use during pregnancy on the rate of neonatal drug withdrawal syndrome, low birth weight, low gestational age, and prenatal care use. Punitive policies criminalize prenatal substance use, or define prenatal substance exposure as child maltreatment in child welfare statutes or as grounds for termination of parental rights. Priority treatment policies are supportive and grant pregnant women priority access to substance use disorder treatment programs. Our empirical strategy relies on administrative data from 2008 to 2018 and a difference-in-differences framework that exploits the staggered implementation of these policies. We find that neonatal drug withdrawal syndrome increases by 10%-18% following the implementation of a punitive policy. This growth is accompanied by modest reductions in prenatal care, which may reflect deterrence from healthcare utilization. In contrast, priority treatment policies are associated with small reductions in low gestational age (2%) and low birth weight (2%), along with increases in prenatal care use. Taken together, our findings suggest that punitive approaches may be associated with unintended adverse pregnancy outcomes, and that supportive approaches may be more effective for improving perinatal health.

Parental drug use and racial and ethnic disproportionality in the U.S. foster care system.

BACKGROUND AND AIMS: Following nearly a decade of entry declines, foster care entries in the United States began to rise steadily since 2012, largely because of dramatic increases in home removals involving parental drug use (PDU). America's ongoing opioid crisis and recent changes in drug policies have been associated with the growth in PDU entries. The extent to which these and other recent factors have affected historical racial/ethnic differences in the foster care system is unknown. We explored the prevalence of racial/ethnic disproportionality and disparity in PDU entries and described children characteristics across racial/ethnic populations. DESIGN: Secondary data analysis of the universe of foster care entries in 2008-2017, obtained from the Adoption and Foster Care Analysis and Reporting System. SETTING: Children ages 0-17 entering foster care in the United States. CASES: A total of 2,489,423 foster care entries, 29% (N=714,085) designated as involving PDU. MEASUREMENTS: The rate of PDU entries was measured as the number of foster care entries involving PDU per 1,000 children ages 0-17 in the general population, by racial/ethnic group. Disproportionality in PDU entries was measured as the proportion of a racial/ethnic group among PDU entries over their proportion among the general population. FINDINGS: From 2008-2017, the rate of PDU entries increased 71% in the general population and across all racial/ethnic groups. Native American children displayed the highest level and fastest growth in PDU entry rates (139%; 1.74 in 2008 to 4.15 in 2017), followed by non-Hispanic White children (112%; 0.70 in 2008 to 1.49 in 2017). Native American children also displayed the highest level of disproportionality in foster care entries, with a representation in PDU entries and other entries about 3.23 and 2.56 times their representation in the general population. CONCLUSIONS: Foster care entries involving PDU increased considerably across all racial/ethnic populations. Growth in PDU entries was greatest among Native American children, exacerbating existing disproportionalities in the foster care system for this vulnerable population.

Foster Care and Health in Medicaid-Enrolled Children Experiencing Parental Opioid Use Disorder.

Importance: The burden of the US opioid crisis has fallen heavily on children, a vulnerable population increasingly exposed to parental opioid use disorder (POUD) in utero or during childhood. A paucity of studies have investigated foster care involvement among those experiencing parental opioid use during childhood and the associated health and health care outcomes. Objective: To examine the health and health care outcomes of children experiencing POUD with and without foster care involvement. Design, Setting, and Participants: This population-based cohort study used nationwide Medicaid claims data from January 1, 2014, to December 31, 2020. Participants included Medicaid-enrolled children experiencing parental opioid use-related disorder during ages 4 to 18 years. Data were analyzed between January 2023 and February 2024. Exposure: Person-years with (exposed) and without (nonexposed) foster care involvement, identified using Medicaid eligibility, procedure, and diagnostic codes. Main Outcomes and Measures: The main outcomes included physical and mental health conditions, developmental disorders, substance use, and health care utilization. The Pearson χ2 test, the t test, and linear regression were used to compare outcomes in person-years with (exposed) and without (nonexposed) foster care involvement. An event study design was used to examine health care utilization patterns before and after foster care involvement. Results: In a longitudinal sample of 8 939 666 person-years from 1 985 180 Medicaid-enrolled children, 49% of children were females and 51% were males. Their mean (SD) age was 10 (4.2) years. The prevalence of foster care involvement was 3% (276 456 person-years), increasing from 1.5% in 2014 to 4.7% in 2020. Compared with those without foster care involvement (8 663 210 person-years), foster care involvement was associated with a higher prevalence of developmental delays (12% vs 7%), depression (10% vs 4%), trauma and stress (35% vs 7%), and substance use-related disorders (4% vs 1%; P < .001 for all). Foster children had higher rates of health care utilization across a wide array of preventive services, including well-child visits (64% vs 44%) and immunizations (41% vs 31%; P < .001 for all). Health care utilization increased sharply in the first year entering foster care but decreased as children exited care. Conclusions and Relevance: In this cohort study of Medicaid-enrolled children experiencing parental opioid use-related disorder, foster care involvement increased significantly between 2014 and 2020. Involvement was associated with increased rates of adverse health outcomes and health care utilization. These findings underscore the importance of policies that support children and families affected by opioid use disorder, as well as the systems that serve them.

Association of Comorbid Behavioral and Medical Conditions With Cannabis Use Disorder in Pregnancy.

Importance: Prenatal cannabis use continues to increase, yet studies of the demographic, psychiatric, and medical characteristics associated with cannabis use in pregnancy are limited by size and use of self-report, and often do not consider cannabis use disorder (CUD) or concomitant substance use disorders (SUDs). Understanding the factors associated with CUD in pregnancy is paramount for designing targeted interventions. Objective: To examine the prevalence of co-occurring psychiatric and medical conditions of US pregnant individuals hospitalized with and without CUD by concomitant SUDs. Design, Setting, and Participants: The study analyzed restricted hospital discharge data from the 2010 to 2018 Healthcare Cost and Utilization Project State Inpatient Databases in 35 states. Data were analyzed from January to August 2021. Weighted linear regressions tested whether the prevalence of psychiatric and medical conditions differed between individuals with and without a CUD diagnosis at hospitalization. Inpatient hospitalizations of pregnant patients aged 15 to 44 years with a CUD diagnosis were identified. Pregnant patients aged 15 to 44 years without a CUD diagnosis were identified for comparison. Patients were further stratified based on concomitant SUD patterns: (1) other SUDs, including at least 1 controlled substance; (2) other SUDs, excluding controlled substances; and (3) no other SUDs. Exposures: CUD in pregnancy. Main Outcomes and Measures: Prevalence of demographic characteristics, psychiatric disorders (eg, depression and anxiety), and medical conditions (eg, epilepsy and vomiting). Results: The sample included 20 914 591 hospitalizations of individuals who were pregnant. The mean (SD) age was 28.24 (5.85) years. Of the total number of hospitalizations, 249 084 (1.19%) involved CUD and 20 665 507 (98.81%) did not. The proportion of prenatal hospitalizations involving CUD increased from 0.008 in 2010 to 0.02 in 2018. Analyses showed significant differences in the prevalence of almost every medical and psychiatric outcome examined between hospitalizations with and without CUD diagnoses, regardless of concomitant SUDs. Elevations were seen in depression (0.089; 95% CI, 0.083-0.095), anxiety (0.072; 95% CI, 0.066-0.076), and nausea (0.036; 95% CI, 0.033-0.040]) among individuals with CUD only at hospitalization compared with individuals with no SUDs at hospitalization. Conclusions and Relevance: Considerable growth was observed in the prevalence of CUD diagnoses among individuals hospitalized prenatally and in the prevalence of depression, anxiety, nausea, and other conditions in individuals with CUD at hospitalization. This study highlights the need for more screening, prevention, and treatment, particularly in populations with co-occurring CUD and psychiatric disorders. Research on the determinants and outcomes associated with CUD during pregnancy is needed to guide clinicians, policy makers, and patients in making informed decisions.

Impact of prenatal substance use policies on commercially insured pregnant females with opioid use disorder.

INTRODUCTION: States' approaches to addressing prenatal substance use are widely heterogeneous, ranging from supportive policies that enhance access to substance use disorder (SUD) treatment to punitive policies that criminalize prenatal substance use. We studied the effect of these prenatal substance use policies (PSUPs) on medications for opioid use disorder (OUD) treatment, including buprenorphine, naltrexone, and methadone, psychosocial services for SUD treatment, opioid prescriptions, and opioid overdoses among commercially insured pregnant females with OUD. We evaluated: (1) punitive PSUPs criminalizing prenatal substance use or defining it as child maltreatment; (2) supportive PSUPs granting pregnant females priority access to SUD treatment; and (3) supportive PSUPs funding targeted SUD treatment programs for pregnant females. METHODS: We analyzed 2006-2019 MarketScan Commercial Claims and Encounters data. The longitudinal sample comprised females aged 15-45 with an OUD diagnosis at least once during the study period. We estimated fixed effects models that compared changes in outcomes between pregnant and nonpregnant females, in states with and without a PSUP, before and after PSUP implementation. RESULTS: Our analytical sample comprised 2,438,875 person-quarters from 164,538 unique females, of which 13% were pregnant at least once during the study period. We found that following the implementation of PSUPs funding targeted SUD treatment programs, the proportion of opioid overdoses decreased 45% and of any OUD medication increased 11%, with buprenorphine driving this increase (13%). The implementation of SUD treatment priority PSUPs was not associated with significant changes in outcomes. Following punitive PSUP implementation, the proportion receiving psychosocial services for SUD (12%) and methadone (30%) services decreased. In specifications that estimated the impact of criminalizing policies only, the strongest type of punitive PSUP, opioid overdoses increased 45%. CONCLUSION: Our findings suggest that supportive approaches that enhance access to SUD treatment may effectively reduce adverse maternal outcomes associated with prenatal opioid use. In contrast, punitive approaches may have harmful effects. These findings support leading medical organizations' stance on PSUPs, which advocate for supportive policies that are centered on increased access to SUD treatment and safeguard against discrimination and stigmatization. Our findings also oppose punitive policies, as they may intensify marginalization of pregnant females with OUD seeking treatment.

Prenatal Substance Use Policies And Infant Maltreatment Reports.

We studied the effect of state punitive and supportive prenatal substance use policies on reports of infant maltreatment to child protection agencies. Punitive policies criminalize prenatal substance use or define it as child maltreatment, whereas supportive policies provide pregnant women with priority access to substance use disorder treatment programs. Using difference-in-differences methods, we found that total infant maltreatment reports increased by 19.0 percent after punitive policy adoption during the years of our study (2004-18). This growth was driven by a 38.4 percent increase in substantiated reports in which the mother was the alleged perpetrator. There were no changes in unsubstantiated reports after the adoption of punitive policies. We observed no changes in infant maltreatment reports after the adoption of supportive policies. Findings suggest that punitive policies lead to large increases in substantiated infant maltreatment reports, which in turn may lead to child welfare system involvement soon after childbirth in states with these policies. Policy makers should design interventions that emphasize support services and improve well-being for mothers and infants.

The Affordable Care Act Increased Medicaid Coverage Among Former Foster Youth.

Youth aging out of the foster care system in the US are a vulnerable population. When in foster care, youth are eligible for their state's Medicaid program, but they lose eligibility when they age out of foster care. The Affordable Care Act (ACA) has the potential to address some of the health care needs of former foster youth through the Medicaid eligibility expansion to low-income adults and by extending Medicaid eligibility up to age twenty-six for former foster youth. Using the 2011-18 National Youth in Transition Database, we found that Medicaid expansion increased Medicaid coverage among former foster youth by 10.1 percentage points, and the age extension increased coverage by 3.4 percentage points. There is suggestive evidence of positive spillovers for both policies. Our findings imply that the ACA improved Medicaid coverage among former foster youth, with the largest effects from Medicaid expansion. The modest effects of the Medicaid age extension may imply a need to revise enrollment, recertification, outreach, and eligibility determination processes to further increase Medicaid coverage among former foster youth.

Illegal drug market responses to state recreational cannabis laws.

BACKGROUND AND AIMS: In the United States, 15 states and the District of Columbia have implemented recreational cannabis laws (RCLs) legalizing recreational cannabis use. We aimed to estimate the association between RCLs and street prices, potency, quality and law enforcement seizures of illegal cannabis, methamphetamine, cocaine, heroin, oxycodone, hydrocodone, morphine, amphetamine and alprazolam. DESIGN: We pooled crowdsourced data from 2010-19 Price of Weed and 2010-19 StreetRx, and administrative data from the 2006-19 System to Retrieve Information from Drug Evidence (STRIDE) and the 2007-19 National Forensic Laboratory Information System (NFLIS). We employed a difference-in-differences design that exploited the staggered implementation of RCLs to compare changes in outcomes between RCL and non-RCL states. SETTING AND CASES: Eleven RCL and 40 non-RCL US states. MEASURES: The primary outcome was the natural log of prices per gram, overall and by self-reported quality. The primary policy was an indicator of RCL implementation, defined using effective dates. FINDINGS: The street price of cannabis decreased by 9.2% [ß = -0.092; 95% confidence interval (CI) = -0.15-, -0.03] in RCL states after RCL implementation, with largest declines among low-quality purchases (ß = -0.195; 95% CI = -0.282, -0.108). Price declines were accompanied by a 93% (ß = -0.93; 95% CI = -1.51, -0.36) reduction in law enforcement seizures of cannabis in RCL states. Among illegal opioids, including heroin, oxycodone and hydrocodone, street prices increased and law enforcement seizures decreased in RCL states. CONCLUSIONS: Recreational cannabis laws in US states appear to be associated with illegal drug market responses in those states, including reductions in the street price of cannabis. Changes in the street prices of illegal opioids analyzed may suggest that in states with recreational cannabis laws the markets for other illegal drugs are not independent of legal cannabis market regulation.

Marijuana liberalization policies and perinatal health.

We studied the effect of marijuana liberalization policies on perinatal health with a multiperiod difference-in-differences estimator that exploited variation in effective dates of medical marijuana laws (MML) and recreational marijuana laws (RML). We found that the proportion of maternal hospitalizations with marijuana use disorder increased by 23% (0.3 percentage points) in the first three years after RML implementation, with larger effects in states authorizing commercial sales of marijuana. This growth was accompanied by a 7% (0.4 percentage points) decline in tobacco use disorder hospitalizations, yielding a net zero effect over all substance use disorder hospitalizations. RMLs were not associated with statistically significant changes in newborn health. MMLs had no statistically significant effect on maternal substance use disorder hospitalizations nor on newborn health and fairly small effects could be ruled out. In absolute numbers, our findings implied modest or no adverse effects of marijuana liberalization policies on the array of perinatal outcomes considered.

Substance use disorder treatment services for pregnant and postpartum women in residential and outpatient settings.

The increasing prevalence of opioid use disorders among pregnant and postpartum women (PPW) has generated a need for greater availability of specialized programs offering evidence-based and comprehensive substance use disorder treatment services tailored to this population. In this study, we used data from the 2007 to 2018 National Survey of Substance Abuse Treatment Services to describe recent time trends and the geographic distribution of treatment facilities with specialized programs for PPW. We also compared differences in the availability of opioid agonist medication treatments (MT), key ancillary services, and health insurance acceptance between PPW Programs and Other Programs, overall and by residential and outpatient settings. We found that the prevalence of PPW Programs increased from 17% in 2007 to 23% in 2018, for a total of 3,429 PPW Programs and 11,230 Other Programs in 2018. The prevalence of PPW Programs was lowest in some states in the South and Midwest. Compared to Other Programs, PPW Programs were more likely to accept Medicaid (75% vs. 64%) and offer opioid agonist MTs methadone (24% vs. 6%), buprenorphine (44% vs. 30%), or both (18% vs. 4%). PPW Programs were also more likely to offer other key ancillary services such as childcare (16% vs. 3%), transportation (50% vs. 42%), and domestic violence assistance (51% vs. 35%). Compared to PPW Programs in outpatient settings, PPW Programs in residential settings were more likely to offer these key ancillary services but less likely to offer methadone or accept Medicaid. Our findings reflect considerable variation in the availability of PPW Programs over time and across states, as well as substantial gaps in key services offered in PPW Programs, let alone in Other Programs.

The impact of the abuse-deterrent reformulation of extended-release OxyContin on prescription pain reliever misuse and heroin initiation.

The introduction of abuse-deterrent OxyContin in 2010 was intended to reduce its misuse by making it more tamper resistant. However, some studies have suggested that this reformulation might have had unintended consequences, such as increases in heroin-related deaths. We used the 2005-2014 cross-sectional U.S. National Survey on Drug Use and Health to explore the impact of this reformulation on intermediate outcomes that precede heroin-related deaths for individuals with a history of OxyContin misuse. Our study sample consisted of adults who misused any prescription pain reliever prior to the reformulation of OxyContin (n = 81,400). Those who misused OxyContin prior to the reformulation were considered the exposed group and those who misused other prescription pain relievers prior to the reformulation were considered the unexposed group. We employed multivariate logistic regression under a difference-in-differences framework to examine the effect of the reformulation on five dichotomous outcomes: prescription pain reliever misuse; prescription pain reliever use disorder; heroin use; heroin use disorder; and heroin initiation. We found a net reduction in the odds of prescription pain reliever misuse (OR:0.791, p < 0.001) and heroin initiation (OR:0.422, p = 0.011) after the reformulation for the exposed group relative to the unexposed group. We found no statistically significant effects of the reformulation on prescription pain reliever use disorder (OR: 0.934, p = 0.524), heroin use (OR: 1.014p = 0.941), and heroin use disorder (OR: 1.063, p = 0.804). Thus, the reformulation of OxyContin appears to have reduced prescription pain reliever misuse without contributing to relatively greater new heroin use among those who misused OxyContin prior to the reformulation.

Medical marijuana laws are associated with increases in substance use treatment admissions by pregnant women.

BACKGROUND AND AIMS: Between 2002 and 2014, past-month marijuana use among pregnant women in the United States increased 62%, nearly twice the growth of the general population. This growth coincides with the proliferation of state medical marijuana laws (MMLs) authorizing physicians to recommend marijuana for approved conditions. We estimated the association between MMLs and substance use treatment utilization among pregnant and non-pregnant women of reproductive age. We also examined whether the association varied across MML provisions, age groups and treatment referral sources to clarify potential pathways. DESIGN: Nation-wide administrative data from the 2002-14 Treatment Episodes Data Set Admissions, and a difference-in-differences design that exploited the staggered implementation of MMLs to compare changes in outcomes before and after implementation between MML and non-MML states. SETTING: Twenty-one MML and 27 non-MML US states. PARTICIPANTS: Pregnant and non-pregnant women aged 12-49 admitted to publicly funded specialty substance use treatment facilities. MEASUREMENTS: The primary outcome variable was the number of treatment admissions per 100 000 women aged 12-49, aggregated at the state-year level (n = 606). Admissions for marijuana, alcohol, cocaine and opioids were considered. The primary independent variable was an indicator of MML implementation in a state. FINDINGS: Among pregnant women, the rate of marijuana treatment admissions increased by 4.69 [95% confidence interval (CI) = 1.32, 8.06] in MML states relative to non-MML states. This growth was accompanied by increases in treatment admissions involving alcohol (ß = 3.19; 95% CI = 0.97, 5.410 and cocaine (ß = 2.56; 95% CI = 0.34, 4.79), was specific to adults (ß = 5.50; 95% CI = 1.52, 9.47) and was largest in states granting legal protection for marijuana dispensaries (ß = 6.37; 95% CI = -0.97, 13.70). There was no statistically significant association between MMLs and treatment admissions by non-pregnant women. CONCLUSIONS: Medical marijuana law implementation in US states has been associated with greater substance use treatment utilization by pregnant adult women, especially in states with legally protected dispensaries.

Prescribing decisions at buprenorphine treatment initiation: Do they matter for treatment discontinuation and adverse opioid-related events?

INTRODUCTION: Buprenorphine is a highly effective medication treatment for opioid use disorder (OUD) that can be prescribed in multiple treatment settings. Treatment retention, however, remains a challenge. In this study, we examined the association of days of supply as well as daily dosage of the initial buprenorphine prescription with treatment discontinuation and adverse opioid-related events following buprenorphine initiation. METHODS: 2011 to 2015 Health Care Cost Institute commercial claims data were analyzed for individuals aged 18-64 years initiating buprenorphine treatment (N = 17,158). Treatment discontinuation was defined as a gap of 30 days or more in buprenorphine use within 180 days of initiation. Adverse opioid-related events were defined as having at least one emergency department visit or inpatient admission involving opioid poisoning, dependence or abuse within 360 days of initiation. We conducted multivariate logistic regressions to estimate adjusted odds ratios of outcomes associated with daily dose (≤4 mg vs. >4 mg) and days of supply (≤7, 8-15, 16-27, or ≥ 28 days) of the initial buprenorphine prescription. RESULTS: Over one-half (55%) of individuals discontinued buprenorphine within 180 days and 13% experienced at least one adverse opioid-related event within 360 days of initiation. Both a lower initial dose [≤4 mg, OR = 1.79, p < 0.01] and fewer initial days of supply [≤7 days vs. ≥28 days, OR = 1.32, p < 0.01] [8-15 days vs. ≥28 days, OR = 1.22, p < 0.01] were associated with increased odds of discontinuation. While a lower initial dose was not associated with adverse events, fewer initial days of supply were associated with a higher risk of adverse events, even after controlling for treatment discontinuation. CONCLUSION: In this population of commercially insured, non-elderly adults, we found that fewer initial days of supply as well as a lower initial dose were associated with increased likelihood of treatment discontinuation, highlighting the importance of prescribing decisions when initiating buprenorphine for OUD.

Patterns in Prescription Opioids, Benzodiazepines, and Stimulants Filled by Pregnant Medicaid Beneficiaries.

This study analyzes patterns in prescriptions filled by pregnant Medicaid beneficiaries for opioids, benzodiazepines, and stimulants.

The role of health insurance on treatment for opioid use disorders: Evidence from the Affordable Care Act Medicaid expansion.

We estimate the effect of health insurance coverage on opioid use disorder treatment utilization and availability by exploiting cross-state variation in effective dates of Medicaid expansions under the Affordable Care Act. Using a difference-in-differences design, we find that aggregate opioid admissions to specialty treatment facilities increased 18% in expansion states, most of which involved outpatient medication-assisted treatment (MAT). Opioid admissions from Medicaid beneficiaries increased 113% without crowding out admissions from individuals with other health insurance. These effects appeared to be driven by market entry of select MAT providers and by greater acceptance of Medicaid payments among existing MAT providers. Moreover, effects were largest in expansion states with comprehensive MAT coverage. Our findings suggest that Medicaid expansions resulted in substantial utilization and availability gains to clinically efficacious and cost-effective pharmacological treatments, implying potential benefits of expanding Medicaid to non-expansion states and extending MAT coverage.

Re-engineering methadone-Cost-effectiveness analysis of a patient-centered approach to methadone treatment.

Methadone maintenance treatment has proven effectiveness in the treatment of opioid use disorder, but significant barriers remain to treatment retention. In a randomized clinical trial, 300 newly-admitted methadone patients were randomly assigned to patient-centered methadone (PCM) v. treatment-as-usual (TAU). In PCM, participants were treated under revised program rules which permitted voluntary attendance at counseling and other changes focused on reducing involuntary discharge, and different staff roles which shifted disciplinary responsibility from the participant's counselor to the supervisor. The study found no significant differences in treatment retention, measures of opioid use, or other patient outcomes. This paper employs an activity-based costing approach to estimate the cost and cost-effectiveness of the two study conditions. We found that service use and costs were similar between PCM and TAU. Specifically, the average cost for PCM patients was $2396 compared to $2292 for standard methadone, while the average length of stay was 2 weeks longer for PCM patients. Incremental cost-effectiveness ratios (ICER) for self-reported heroin use, opioid positive urine screens, and meeting DSM-IV criteria for opioid dependence were mixed, with TAU achieving non-significantly better outcomes at lower treatment episode costs (i.e., economically dominating) for opioid positive urine screens. PCM patients reported slightly more days abstinent from heroin and fewer meet the opioid dependence criteria. While these differences are small and not statistically significant, we can still examine the cost-effectiveness implications. For days, abstinent from heroin, the ICER was $242 for one additional day of abstinence, however, there was notable uncertainty around this estimate. For opioid dependence criteria, the ICER was $1160 for a one-percentage point increase in the probability that a participant no longer met criteria for opioid dependence at follow-up. This economic study finds that patient choice concepts can be introduced into methadone treatment without significant impacts on costs or patient outcomes.

Medical Decision-Making Processes and Online Behaviors Among Cannabis Dispensary Staff.

BACKGROUND: Most cannabis patients engage with dispensary staff, like budtenders, for medical advice on cannabis. Yet, little is known about these interactions and how the characteristics of budtenders affect these interactions. This study investigated demographics, workplace characteristics, medical decision-making, and online behaviors among a sample of budtenders. METHODS: Between June and September 2016, a cross-sectional Internet survey was administered to budtenders in the San Francisco Bay Area and Greater Los Angeles. A total of 158 budtenders fully responded to the survey. A series of comparisons were conducted to determine differences between trained and untrained budtenders. RESULTS: Among the 158 budtenders, 56% had received formal training to become a budtender. Several demographic differences were found between trained and untrained budtenders. For workplace characteristics, trained budtenders were more likely to report budtender as their primary job (74% vs 53%), practice more than 5 years (34% vs 11%), and receive sales commission (57% vs 16%). Trained budtenders were significantly less likely to perceive medical decision-making as very important (47% vs 68%) and have a patient-centered philosophy (77% vs 89%). Although trained budtenders had significantly lower Internet usage, they were significantly more likely to exchange information with patients through e-mail (58% vs 39%), text message (46% vs 30%), mobile app (33% vs 11%), video call (26% vs 3%), and social media (51% vs 23%). CONCLUSIONS: Budtenders who are formally trained exhibit significantly different patterns of interaction with medical cannabis patients. Future studies will use multivariate methods to better determine which factors independently influence interactions and how budtenders operate after the introduction of regulations under the newly passed Proposition 64 that permits recreational cannabis use in California.