Comparing Cannabis Use for Pain to Use for Other Reasons in Primary Care Patients.

BACKGROUND: Medical cannabis is commonly used for chronic pain, but little is known about differences in characteristics, cannabis use patterns, and perceived helpfulness among primary care patients who use cannabis for pain versus nonpain reasons. METHODS: Among 1688 patients who completed a 2019 cannabis survey administered in a health system in Washington state, where recreational use is legal, participants who used cannabis for pain (n = 375) were compared with those who used cannabis for other reasons (n = 558) using survey and electronic health record data. We described group differences in participant characteristics, use patterns, and perceptions and applied adjusted multinomial logistic and modified Poisson regression. RESULTS: Participants who used cannabis for pain were significantly more likely to report using applied (50.7% vs 10.6%) and beverage cannabis products (19.2% vs 11.6%), more frequent use (47.1% vs 33.1% for use ≥2 times per day; 81.6% vs 69.7% for use 4 to 7 days per week), and smoking tobacco cigarettes (19.2% vs 12.2%) than those who used cannabis for other reasons. They were also significantly more likely to perceive cannabis as very/extremely helpful (80.5% vs 72.7%), and significantly less likely to use cannabis for nonmedical reasons (4.8% vs 58.8%) or report cannabis use disorder symptoms (51.7% vs 61.1%). DISCUSSION: Primary care patients who use cannabis for pain use it more frequently, often in applied and ingested forms, and have more co-use of tobacco, which may differentially impact safety and effectiveness. These findings suggest the need for different approaches to counseling in clinical care.

Cannabis and nicotine co-use among primary care patients in a state with legal cannabis access.

The aim of this exploratory analysis was to evaluate cannabis exposure, reasons for use and problematic cannabis use among adult primary care patients in Washington state (United States) who co-use cannabis and nicotine (tobacco cigarettes and/or nicotine vaping) compared to patients who endorse current cannabis use only. As part of a NIDA Clinical Trials Network (CTN) parent study, patients who completed a cannabis screen as part of routine primary care were randomly sampled (N = 5,000) to a receive a confidential cannabis survey. Patients were stratified and oversampled based on the frequency of past-year cannabis use and for Black, indigenous, or other persons of color. Patients who endorsed past 30-day cannabis use are included here (N = 1388). Outcomes included; prevalence of cannabis use, days of cannabis use per week and times used per day, methods of use, THC:CBD content, non-medical and/or medical use, health symptoms managed, and cannabis use disorder (CUD) symptom severity. We conducted unadjusted bivariate analyses comparing outcomes between patients with cannabis and current nicotine co-use to patients with cannabis-only use. Nicotine co-use (n = 352; 25.4 %) was associated with differences in method of cannabis use, THC:CBD content, days of use per week and times used per day, number of health symptoms managed, and CUD severity (all p < 0.001), compared to primary care patients with cannabis-only use (n = 1036). Interventions targeting cannabis and nicotine co-use in primary care are not well-established and further research is warranted given findings of more severe cannabis use patterns and the adverse health outcomes associated with co-use.

Validity of the Single-Item Screen-Cannabis (SIS-C) for Cannabis Use Disorder Screening in Routine Care.

Importance: Cannabis use is prevalent and increasing, and frequent use intensifies the risk of cannabis use disorder (CUD). CUD is underrecognized in medical settings, but a validated single-item cannabis screen could increase recognition. Objective: To evaluate the Single-Item Screen-Cannabis (SIS-C), administered and documented in routine primary care, compared with a confidential reference standard measure of CUD. Design, Setting, and Participants: This diagnostic study included a sample of adult patients who completed routine cannabis screening between January 28 and September 12, 2019, and were randomly selected for a confidential survey about cannabis use. Random sampling was stratified by frequency of past-year use and race and ethnicity. The study was conducted at an integrated health system in Washington state, where adult cannabis use is legal. Data were analyzed from May 2021 to March 2022. Exposures: The SIS-C asks about frequency of past-year cannabis use with responses (none, less than monthly, monthly, weekly, daily or almost daily) documented in patients' medical records. Main Outcomes and Measures: The Diagnostic and Statistical Manual, Fifth Edition (DSM-5) Composite International Diagnostic Interview-Substance Abuse Module (CIDI-SAM) for past-year CUD was completed on a confidential survey and considered the reference standard. The SIS-C was compared with 2 or more criteria on the CIDI-SAM, consistent with CUD. All analyses were weighted, accounting for survey design and nonresponse, to obtain estimates representative of the health system primary care population. Results: Of 5000 sampled adult patients, 1688 responded to the cannabis survey (34% response rate). Patients were predominantly middle-aged (weighted mean [SD] age, 50.7 [18.1]), female or women (weighted proportion [SE], 55.9% [4.1]), non-Hispanic (weighted proportion [SE], 96.7% [1.0]), and White (weighted proportion [SE], 74.2% [3.7]). Approximately 6.6% of patients met criteria for past-year CUD. The SIS-C had an area under receiver operating characteristic curve of 0.89 (95% CI, 0.78-0.96) for identifying CUD. A threshold of less than monthly cannabis use balanced sensitivity (0.88) and specificity (0.83) for detecting CUD. In populations with a 6% prevalence of CUD, predictive values of a positive screen ranged from 17% to 34%, while predictive values of a negative screen ranged from 97% to 100%. Conclusions and Relevance: In this diagnostic study, the SIS-C had excellent performance characteristics in routine care as a screen for CUD. While high negative predictive values suggest that the SIS-C accurately identifies patients without CUD, low positive predictive values indicate a need for further diagnostic assessment following positive results when screening for CUD in primary care.

Cannabis use, other drug use, and risk of subsequent acute care in primary care patients.

BACKGROUND: Cannabis and other drug use is associated with adverse health events, but little is known about the association of routine clinical screening for cannabis or other drug use and acute care utilization. This study evaluated whether self-reported frequency of cannabis or other drug use was associated with subsequent acute care. METHOD: This retrospective cohort study used EHR and claims data from 8 sites in Washington State that implemented annual substance use screening. Eligible adult primary care patients (N = 47,447) completed screens for cannabis (N = 45,647) and/or other drug use, including illegal drug use and prescription medication misuse, (N = 45,255) from 3/3/15-10/1/2016. Separate single-item screens assessed frequency of past-year cannabis and other drug use: never, less than monthly, monthly, weekly, daily/almost daily. An indicator of acute care utilization measured any urgent care, emergency department visits, or hospitalizations ≤19 months after screening. Adjusted Cox proportional hazards models estimated risk of acute care. RESULTS: Patients were predominantly non-Hispanic White. Those reporting cannabis use less than monthly (Hazard Ratio [HR] = 1.12, 95 % CI = 1.03-1.21) or daily (HR = 1.24; 1.10-1.39) had greater risk of acute care during follow-up than those reporting no use. Patients reporting other drug use less than monthly (HR = 1.34; 1.13-1.59), weekly (HR = 2.21; 1.46-3.35), or daily (HR = 2.53; 1.86-3.45) had greater risk of acute care than those reporting no other drug use. CONCLUSION: Population-based screening for cannabis and other drug use in primary care may have utility for understanding risk of subsequent acute care. It is unclear whether findings will generalize to U.S. states with broader racial/ethnic diversity.

Patient-centered primary care for adults at high risk for AUDs: the Choosing Healthier Drinking Options In primary CarE (CHOICE) trial.

BACKGROUND: Most patients with alcohol use disorders (AUDs) never receive alcohol treatment, and experts have recommended management of AUDs in primary care. The Choosing Healthier Drinking Options In primary CarE (CHOICE) trial was a randomized controlled effectiveness trial of a novel intervention for primary care patients at high risk for AUDs. This report describes the conceptual and scientific foundation of the CHOICE model of care, critical elements of the CHOICE trial design consistent with the Template for Intervention Description and Replication (TIDieR), results of recruitment, and baseline characteristics of the enrolled sample. METHODS: The CHOICE intervention is a multi-contact, extended counseling intervention, based on the Chronic Care Model, shared decision-making, motivational interviewing, and evidence-based options for managing AUDs, designed to be practical in primary care. Outpatients who received care at 3 Veterans Affairs primary care sites in the Pacific Northwest and reported frequent heavy drinking (≥4 drinks/day for women; ≥5 for men) were recruited (2011-2014) into a trial in which half of the participants would be offered additional alcohol-related care from a nurse. CHOICE nurses offered 12 months of patient-centered care, including proactive outreach and engagement, repeated brief motivational interventions, monitoring with and without alcohol biomarkers, medications for AUDs, and/or specialty alcohol treatment as appropriate and per patient preference. A CHOICE nurse practitioner was available to prescribe medications for AUDs. RESULTS: A total of 304 patients consented to participate in the CHOICE trial. Among consenting participants, 90% were men, the mean age was 51 (range 22-75), and most met DSM-IV criteria for alcohol abuse (14%) or dependence (59%). Many participants also screened positive for tobacco use (44%), depression (45%), anxiety disorders (30-41%) and non-tobacco drug use disorders (19%). At baseline, participants had a median AUDIT score of 18 [Interquartile range (IQR) 14-24] and a median readiness to change drinking score of 5 (IQR 2.75-6.25) on a 1-10 Likert scale. CONCLUSION: The CHOICE trial tested a patient-centered intervention for AUDs and recruited primary care patients at high risk for AUDs, with a spectrum of severity, co-morbidity, and readiness to change drinking. Trial registration The trial is registered at clinicaltrial.gov (NCT01400581).