Why Are Adolescent Cannabis Use Disorder Treatment Admissions Declining in the US? The Mediated Pathway of State Treatment Admissions Rates before and after Recreational Cannabis Legalization.

Purpose: State-level prevalence data are used to investigate whether recreational cannabis legalization moderates the mediated pathway from the perception of low risk of harm, to cannabis use, to cannabis use disorder (CUD) treatment admissions, among adolescents (age 12-17) in the US. Methods: Annual state prevalence measures of perception of low risk, cannabis use, and CUD treatment admissions between 2008 and 2019 (N = 542 state-year observations) were collected from the National Survey on Drug Use and Health (NSDUH) and the Treatment Episode Dataset - Admissions (TEDS-A). A two-way fixed effects (state and year) moderated mediation model was used to test whether recreational legalization moderated the indirect effect of perception of low risk on treatment admissions via cannabis use. Results: A positive indirect effect of perceiving cannabis as low risk on CUD treatment admissions via cannabis use was observed prior to legalization but not afterwards. After legalization, the positive association of perceiving cannabis as low risk with cannabis use was strengthened, and the positive association of cannabis use with treatment admissions was suppressed, as compared to before legalization. Discussion: Recreational legalization may alter the social acceptability and medical self-administration of cannabis, potentially leading to CUD treatment utilization decline among adolescents even as risk factors for CUD increase. Linking recreational cannabis legalization to advancing awareness of the health risks associated with adolescent cannabis use and promoting adolescent CUD treatment engagement through mHealth approaches and primary care providers are key to addressing potential adolescent health challenges brought about by expanding cannabis legalization.

Criminal Justice Referrals to Cannabis Use Disorder Treatment among Adolescents and Young Adults following Recreational Cannabis Legalization in the United States.

OBJECTIVES: This study investigates whether the proportion of referrals to cannabis use disorder (CUD) treatment from the criminal justice system declined among adolescents (aged 12-17 years) and young adults (aged 18-24 years) following state recreational (adult use) cannabis legalization in the United States between 2008 and 2019. METHODS: Cannabis use disorder treatment referral data were extracted from the Treatment Episode Dataset-Admissions and used to calculate trends in the number and proportion of criminal justice referrals. Difference-in-differences analysis was used to estimate the effect of recreational legalization on the state-level proportion of criminal justice referrals as a share of all admissions. RESULTS: Nationwide, the number and proportion of adolescent and young adult criminal justice referrals to CUD treatment declined over the study period. The proportion of young adult criminal justice referrals declined significantly more rapidly after recreational legalization as compared with before ( ß = -0.045; 95% confidence interval, -0.079 to -0.010; P = 0.01). Among adolescents, the trajectory of decline in the proportion of criminal justice referrals did not change significantly following recreational legalization ( ß = -0.033; 95% confidence interval, -0.073 to 0.008; P = 0.11). CONCLUSIONS: The decline in the proportion of young adult criminal justice referrals to CUD treatment following recreational legalization is likely due to falling cannabis-related arrests. Although cannabis criminalization may result in court-mandated CUD treatment for some young adults without CUD, the decline in CUD treatment admissions during a period of increasing CUD risk factors associated with recreational legalization represents a key health concern. Promoting screening and other CUD treatment referral sources, such as through primary care, may be warranted.

Recreational cannabis legalization alters associations among cannabis use, perception of risk, and cannabis use disorder treatment for adolescents and young adults.

OBJECTIVE: Understanding how recreational cannabis legalization may impact cannabis use disorder (CUD) among adolescents and young adults is key to developing an appropriate public health response. This research investigates whether associations among adolescent and young adult perception of risk of harm from cannabis use, prevalence of past-month cannabis use, and rate of CUD treatment admissions changed following recreational cannabis legalization in the US, 2008-2019. METHODS: Data from the NSDUH and TEDS-A datasets are employed in difference-in-differences models of the effect of recreational legalization on perception of risk, cannabis use prevalence, and CUD treatment admissions. Moderated models test whether associations among variables changed following recreational legalization. RESULTS: Following recreational legalization: 1) adolescent and young adult past-month cannabis use prevalence increased; 2) among both adolescents and young adults, the association of lower perception of risk of harm with higher cannabis use prevalence was strengthened; 3) among adolescents, the association of higher cannabis use prevalence with higher CUD treatment admissions was suppressed; and 4) among young adults, an association of higher cannabis use prevalence with lower CUD treatment admissions emerged. CONCLUSIONS: Recreational legalization is likely to increase cannabis use among adolescents and young adults who perceive cannabis as less harmful, while at the same time reduce rates of CUD treatment utilization. These trends portend an increase in unmet need for CUD treatment for age groups particularly vulnerable to the development and negative consequences of CUD.

Young adult cannabis use disorder treatment admissions declined as past month cannabis use increased in the U.S.: An analysis of states by year, 2008-2017.

OBJECTIVE: This short communication reports on the association of annual measures of young adult (age 18-24) past month cannabis use with cannabis use disorder (CUD) treatment admissions by state in the U.S. from 2008 to 2017. METHODS: Annual data on percentage of past month cannabis use and the total number of CUD treatment admissions among young adults were acquired for each state from SAMHSA NSDUH and TEDS-A data sets. For each state, the correlation over time between cannabis use and treatment admissions rate was calculated and visualized in a choropleth map. Fixed-effects regression, where effects are fixed by state, was used to investigate the association of cannabis use with treatment admissions rate. RESULTS: In 38 out of 50 states, including seven out of the eight states legalizing recreational cannabis during the study period, as young adult cannabis use increased, treatment admissions declined. Cannabis use is significantly and negatively associated with treatment admissions (ß = -7.21, 95% CI = -11.88, -2.54), even after controlling for health insurance coverage, criminal justice referral, treatment center availability, and cannabis legalization status. CONCLUSIONS: While it is possible that across the U.S. more young adults are using cannabis without developing CUD, we speculate that increasing social acceptance of cannabis use, and declining perception of harm, may influence treatment seeking behavior, potentially resulting in growing unmet need for CUD treatment among young adults. Monitoring state-level trends in cannabis use, CUD prevalence, and treatment admissions is key to developing CUD prevention and treatment policies targeted to timely, state-specific conditions.

Residential Greenspace and Urban Adolescent Substance Use: Exploring Interactive Effects with Peer Network Health, Sex, and Executive Function.

While urban greenspace is increasingly recognized as important to mental health, its role in substance use is understudied. This exploratory study investigates the interaction of greenspace with peer network health, sex, and executive function (EF) in models of substance use among a sample of disadvantaged, urban youth. Adolescents and their parents were recruited from a hospital in the mid-Atlantic region of the U.S. Residential greenspace at the streetscape level was derived from analysis of Google Street View imagery. Logistic regression models were used to test the moderating effect of greenspace on the association between peer network health and substance use, as well as additional moderating effects of sex and EF. The significant negative association of peer network health with substance use occurred only among youth residing in high greenspace environments, a moderating effect which was stronger among youth with high EF deficit. The moderating effect of greenspace did not differ between girls and boys. Greenspace may play an important role in moderating peer influences on substance use among disadvantaged, urban adolescents, and such moderation may differ according to an individual's level of EF. This research provides evidence of differences in environmental susceptibility regarding contextual mechanisms of substance use among youth, and it informs the development of targeted substance use interventions that leverage social and environmental influences on adolescent substance use.

Treatment admissions for opioids, cocaine, and methamphetamines among adolescents and emerging adults after legalization of recreational marijuana.

BACKGROUND: A public health concern stemming from recreational marijuana legalization (RML) is the idea that marijuana may act as a "gateway" drug among youth and young adults, where growing marijuana use will lead to increasing substance use disorder (SUD) for "harder" illicit drugs. This study investigates whether SUD treatment admissions for cocaine, opioids, and methamphetamines increased following RML enactment in Colorado and Washington for adolescents and emerging adults. METHODS: We entered annual 2008-2017 treatment admissions data from the SAMHSA Treatment Episode Dataset - Admissions (TEDS-A) into difference-in-differences models to investigate whether the difference in treatment admissions for cocaine, opioids, and methamphetamines among adolescents (12-17), early emerging adults (18-20), and late emerging adults (21-24) before versus after RML enactment differed between Colorado and Washington and states without RML. RESULTS: There was no significant difference (p < 0.05) between Colorado and Washington and other states in the pre- versus postlegalization trajectories of SUD treatment admissions for cocaine, opioids, or methamphetamines for adolescents (ß = -0.152, 95% CI = -0.500, 0.196; ß = -0.374, 95% CI = -1.188, 0.439; ß = 0.787, 95% CI = -0.511, 2.084, respectively), early emerging adults (ß = -0.153, 95% CI = -0.762, 0.455; ß = 0.960, 95% CI = -4.771, 6.692; ß = 0.406, 95% CI = -2.232, 3.044, respectively) or late emerging adults (ß = -0.347, 95% CI = -1.506, 0.812; ß = -4.417, 95% CI = -16.264, 7.431; ß = 1.804, 95% CI = -2.315, 5.923, respectively). CONCLUSION: RML in Washington and Colorado was not associated with an increase in adolescent or emerging adult SUD treatment admissions for opioids, cocaine, or methamphetamines. Future studies should extend this research to other states, other substances, for older adults, and over longer time periods; and consider how the effects of drug policies may differ across different jurisdictions.

Adolescent treatment admissions for marijuana following recreational legalization in Colorado and Washington.

INTRODUCTION: There is concern that recreational marijuana legalization (RML) may lead to increased cannabis use disorder (CUD) among youth due to increased marijuana use. This study investigates whether adolescent substance use disorder treatment admissions for marijuana use increased in Colorado and Washington following RML. METHODS: Annual data on 2008-2017 treatment admissions for marijuana use from the SAMHSA TEDS-A dataset for adolescents age 12-17 were used to model state treatment admissions trends. Difference-in-differences models were used to investigate whether treatment admissions increased following RML in Colorado/Washington compared to non-RML states, after adjusting for socioeconomic characteristics and treatment availability. RESULTS: Over all states in the analysis, the rate of adolescent treatment admissions for marijuana use declined significantly over the study period (ß=-3.375, 95 % CI=-4.842, -1.907), with the mean rate falling nearly in half. The decline in admissions rate was greater in Colorado and Washington compared to non-RML states following RML, though this difference was not significant (ß=-7.671, 95 % CI=-38.798, 23.456). CONCLUSION: Adolescent treatment admissions for marijuana use did not increase in Colorado and Washington following RML. This may be because youth marijuana use did not increase, CUD did not increase (even if use did increase), or treatment seeking behaviors changed due to shifts in attitudes and perceptions of risk towards marijuana use.

Residential and outpatient treatment completion for substance use disorders in the U.S.: Moderation analysis by demographics and drug of choice.

BACKGROUND: This study investigates the impact of residential versus outpatient treatment setting on treatment completion, and how this impact might vary by demographic characteristics and drug of choice, using a national sample of publicly funded substance abuse programs in the United States. METHODS: This is a retrospective analysis using data extracted from the 2011 Substance Abuse and Mental Health Services Administration (SAMHSA) Treatment Episode Data Set (TEDS-D). A total of 318,924 cases were analyzed using logistic regression, fixed-effects logistic regression, and moderated fixed-effects logistic regression. RESULTS: Residential programs reported a 65% completion rate compared to 52% for outpatient settings. After controlling for other confounding factors, clients in residential treatment were nearly three times as likely as clients in outpatient treatment to complete treatment. The effect of residential treatment on treatment completion was not significantly moderated by gender, but it was for age, drug of choice, and race/ethnicity. Residential compared to outpatient treatment increased the likelihood of completion to a greater degree for older clients, Whites, and opioid abusers, as compared to younger clients, non-Whites, and alcohol and other substance users, respectively. CONCLUSION: We speculate that for opioid abusers, as compared to abusers of other drugs, residential treatment settings provide greater protection from environmental and social triggers that may lead to relapse and non-completion of treatment. Greater use of residential treatment should be explored for opioid users in particular.

Dimensions of religiosity and access to religious social capital: correlates with substance use among urban adolescents.

Although some evidence indicates that religiosity may be protective against substance use in the urban youth population, limited research has investigated the effects of multiple dimensions of religiosity on substance use in this population. In this study, a sample of 301 urban adolescents was used (a) to test the effects of three dimensions of religiosity (social religiosity, perceived religious support, and private religiosity) as well as proximity to religious institutions and (b) to determine their correlates with tobacco, alcohol, and marijuana use. It was hypothesized that all three dimensions of religiosity would act as protective factors against all types of substance use and that proximity to religious institutions from adolescents' routine locations would also serve as a protective factor against any type of substance use. Results of logistic regression analysis showed that social religiosity and perceived religious support were protective against marijuana and tobacco use, respectively. Private religiosity was not protective against any type of substance use. Proximity to religious institutions was protective against alcohol use. These findings suggest the importance of examining multiple dimensions of religiosity when investigating substance use in urban youth and offer initial evidence of the importance of proximity to religious institutions as a protective factor against substance use.