Human-centered design approach to building a transition readiness mHealth intervention for early adolescents.

OBJECTIVE: Mobile health (mHealth) interventions may be an efficacious strategy for promoting health behaviors among pediatric populations, but their success at the implementation stage has proven challenging. The purpose of this article is to provide a blueprint for using human-centered design (HCD) methods to maximize the potential for implementation, by sharing the example of a youth-, family-, and clinician-engaged process of creating an mHealth intervention aimed at promoting healthcare transition readiness. METHOD: Following HCD methods in partnership with three advisory councils, we conducted semistructured interviews with 13- to 15-year-old patients and their caregivers in two phases. In Phase 1, participants described challenges during the transition journey, and generated ideas regarding the format, content, and other qualities of the mHealth tool. For Phase 2, early adolescents and caregivers provided iterative feedback on two sequential intervention prototypes. Data were analyzed using thematic analysis in Phase 1 and the rapid assessment process for Phase 2. RESULTS: We interviewed 11 youth and 8 caregivers. The sample included adolescents with a range of chronic health conditions. In Phase 1, participants supported the idea of developing an autonomy-building tool, delivering transition readiness education via social media style videos. In Phase 2, participants responded positively to the successive prototypes and provided suggestions to make information accessible, relatable, and engaging. CONCLUSIONS: The procedures shared in this article could inform other researchers' plans to apply HCD in collaboration with implementation partners to develop mHealth interventions. Our future directions include iteratively developing more videos to promote transition readiness and implementing the intervention in clinical care.

Randomized pilot trial of cell phone support to improve medication adherence among adolescents and young adults with chronic health conditions.

Introduction: Adolescents and young adults (AYA) living with chronic medical conditions often struggle to develop medication adherence skills. This pilot trial evaluated the impact of a mobile health coaching intervention, Cell Phone Support (CPS), on medication adherence. Methods: Interventions in this randomized trial were CPS delivered by phone calls (CPS-C), CPS delivered by text messages (CPS-T), or automated text message reminders (ATR). Participants were AYA with different chronic medical conditions (i.e., sickle cell disease, solid organ transplant, type 2 diabetes), aged 15-20 years (N = 34). We examined the feasibility, acceptability, and preliminary efficacy of each intervention. Results: We examined the feasibility, acceptability, and preliminary efficacy of both CPS interventions. CPS was feasible and acceptable. There was evidence that participants found CPS to be more useful than ATR. In this pilot trial, participants receiving CPS reported relatively stronger increases in adherence, compared to those assigned to ATR. CPS-C slightly outperformed CPS-T. Conclusions: Providing coaching to AYA struggling with illness self-management via their cell phones may promote their acquisition of medication adherence skills. Although larger studies are needed to confirm the results of this pilot study, phone calls and text messages are both promising modalities for delivering human cell phone support. Trial registration: This trial was registered prospectively at ClinicalTrials.gov (NCT04241627) on 1/27/2020.

Youth perspectives on mobile health adherence interventions: A qualitative study guided by the supportive accountability model.

OBJECTIVE: We applied a Supportive Accountability Model lens to understand how youth view remote human coaching versus automated reminders targeting medication adherence. METHODS: We used thematic analysis to interpret (N = 22) youths' responses to semi-structured interviews after 12 weeks of mobile health intervention. RESULTS: Participants reported that both coaching and automated reminders prompted them to take medication, improving their adherence. Participants found coaching helpful because they developed routines and strategies, were motivated to avoid disappointing their coach, and felt their coach cared for them. Automated support could be motivational for some but demanded less engagement. Participants described phone calls as disruptive to their daily lives, but conducive to developing a personal connection with their coach, whereas texts were easier and more flexible. Youth emphasized that individual preferences often differ. CONCLUSION: Human coaching was viewed as a more potent, engaging adherence intervention than automated reminders, although individual needs and preferences differed. Phone calls may enhance the experience of supportive accountability for adherence, but also pose greater acceptability and usability barriers than texting. PRACTICE IMPLICATIONS: Intervention developers should provide opportunities for youth to make personal connections with human adherence supporters and attend to youth preferences for communication modality.

Pediatric subspecialty healthcare providers' views of recruitment during a randomized controlled trial of a mobile health intervention.

Background: Randomized clinical trials (RCTs) enrolling pediatric populations often struggle with recruitment. Engaging healthcare providers in the recruitment process may increase patients' and caregivers' willingness to participate in research. The purpose of this study was to understand the perspectives of pediatric subspecialty healthcare providers considering recruiting patients to participate in an mobile health (mHealth) RCT. Methods: We conducted 9 semi-structured interviews and 1 focus group with a total of N = 11 providers from various disciplines before the initiation of an mHealth RCT addressing medication nonadherence. Then, we conducted 5 follow-up interviews and 1 follow-up focus group with a total of 8 of these providers several months later. We used thematic analysis to generate themes describing providers' views of the RCT and patient recruitment. Results: Providers indicated that they were willing to recruit for this study because they believed that the intervention sought to address a significant problem. They also thought it made sense to intervene using technology for this age group. However, many providers thought that certain patients (e.g., those with mild, shorter-lasting adherence difficulties) were the most appropriate to recruit. They described how keeping the trial front of mind facilitated recruitment, and they advised researchers to use strategies to promote their ongoing awareness of the study if conducting similar research in the future. Conclusion: Pediatric healthcare providers are important stakeholders in mHealth intervention research. Engaging them in participant recruitment is a complex endeavor that might promote patient enrollment, but their views of research and demanding clinical roles are important to understand when designing study procedures.

The process of capacity-building for pediatric subspecialty providers to address the needs of adolescents and young adults with chronic illness.

Approximately 12% of adolescents in the USA live with a chronic health condition. Although youth with chronic illness visit healthcare providers more than healthy peers, pediatric subspecialty providers are less likely to address developmentally relevant concerns (e.g., reproductive health) with adolescents and young adults (AYA), particularly youth of color and/or youth in low-income communities. Despite the documented need for increased training, there remains a general lack of knowledge about pediatric subspecialty providers' training needs related to building their capacity to provide developmentally appropriate care to their adolescent and young adult patients. The present study describes an overall process for capacity-building to address the needs of diverse AYA patients with chronic medical conditions, built upon data representing key stakeholders and staff from 14 specialty care departments collected via quantitative surveys and focus groups. We describe the development of trainings for pediatric subspecialty providers from a large, urban, pediatric tertiary care center to address the health and psychosocial-related concerns of AYA living with chronic illness. We highlight valuable lessons from the capacity-building process in terms of increasing the ability of providers in a major pediatric healthcare center to provide developmentally appropriate care for AYA living with chronic illness. Finally, based on the results of our study, we provide recommendations on how to employ such a process in similar pediatric hospital settings.

Designing an mHealth Roadmap for the Journey to Self-Management: A Qualitative Study with Adolescents and Young Adults Living with Chronic Illness.

OBJECTIVES: Adolescents and young adults (AYA) with chronic illnesses often struggle with illness self-management. The objective of this study is to understand how AYA with various chronic illnesses develop self-management skills and which mobile health (mHealth) strategies they believe could be helpful. METHODS: Semi-structured interviews were conducted with patients, between 16 to 20 years old, living with at least one chronic illness (N = 19), between 2018 and 2019 in Los Angeles, CA. Three coders completed thematic coding to understand how AYA develop and maintain self-management skills, to inform the development of mHealth interventions appropriate across a variety of chronic conditions. RESULTS: Results suggest that AYA develop self-management skills through several strategies, including (1) getting organized, (2) making it work for me and (3) keeping the right mentality. AYA described developing these strategies through: (1) receiving social support, (2) accessing helpful tools and technologies, and (3) going through a maturation process. They provided recommendations for mHealth intervention developers. DISCUSSION: The results suggest that an appealing mHealth intervention could support AYA patients in proactively acquiring self-management skills and prevent having to rely on trial and error or uneven access to guidance and support. Interventions should be responsive to individual technology preferences and practices.

Associations of Reproductive Health Concerns, Health-Related Quality of Life, and Stress Among Adolescents and Young Adults with Chronic Illness.

OBJECTIVE: Adolescents and young adults (AYA) living with chronic illness are as sexually active and interested in having children as healthy peers. Few studies have examined the intersection of managing chronic illness and concerns about realizing reproductive goals, including fertility, pregnancy, childbirth, and parenting. Even less is understood regarding how these concerns might be associated with psychological distress. This study examines associations between the reproductive health concerns (RHC) and health-related stress of AYA patients living with chronic conditions including rheumatologic, cardiac, pulmonology, gastrointestinal disorders, and solid organ transplant. METHODS: A total of 140 patients aged 15 to 20 years (68% female; 81% Hispanic/Latinx) recruited from a transition program located at a safety-net pediatric institution completed surveys examining multiple dimensions of RHC and health-related quality of life (life satisfaction, illness burden, and illness-related anxiety) and condition-related stress. Exploratory factor analyses of RHC variables yielded 3 factors used in regression analyses to identify convergent validity of RHC factors with health-related mental health measures. RESULTS: Three RHC factor loadings emerged: concern about availability to raise children (timing/future), impact of condition/medication on fertility and childbearing (pregnancy/fertility), and impact of condition on motivation to have children (motivation/decision-making). Positive associations were found between all RHC factors and illness-related anxiety; condition-related stress was associated with motivation/decision-making. CONCLUSION: RHC, health-related anxiety, and stress can impede healthy sexual and reproductive health and development of AYA living with chronic conditions. Providers' proactive exploration of patients' concerns about their reproductive future can offer critical support as they navigate the unique existential challenges of early adulthood.

COVID-19's Impact on Substance Use and Well-Being of Younger Adult Cannabis Users in California: A Mixed Methods Inquiry.

Few qualitative studies have examined the impact of COVID-19 on cannabis and alcohol use, and overall well-being among cannabis users. Cannabis users (aged 26-32) were surveyed quantitatively (n=158) and interviewed qualitatively (n=29) in April 2020-May 2021 in Los Angeles. 63.3% of the quantitative sample reported increasing use of either cannabis (29.1%) or alcohol (15.2%) or both (19.0%) following the COVID-19 outbreak. Qualitative data revealed that increases in cannabis and alcohol use were largely attributed to changes in employment and staying at home resulting in fewer impediments and boredom. Themes of loneliness and utilization of various coping strategies were more pronounced among those who increased cannabis and/or alcohol use. For some, increases in cannabis/alcohol use were temporary until participants adjusted to "a new normal" or embraced more adaptive coping strategies. Results suggest monitoring cannabis/alcohol use trends and identifying coping strategies to reduce the pandemic's impact on substance use and mental health.

Coping Motives Mediate the Association of Trauma History with Problematic Cannabis Use in Young Adult Medical Cannabis Patients and Non-Patient Cannabis Users.

Background: Despite evidence of the contribution of childhood trauma to the development of problematic cannabis use, its mediating pathways are largely unknown. Given the link between cannabis motives with trauma and problematic cannabis use, motives of use may represent a construct through which trauma impacts problematic cannabis use. Methods: A sample of 339 medical cannabis patient and non-patient young adult users from the Los Angeles area were sampled at baseline and one year later. The current study examined the impact of childhood trauma on problematic use through a variety of cannabis use motives. Results: Controlling for age, socioeconomic status, perceived stress, and baseline problematic use, endorsing the use of cannabis to cope with distress at baseline uniquely mediated the associations between different childhood trauma types (e.g., physical abuse, neglect, sexual trauma) and problematic use one year later. Experience of any childhood trauma was positively associated with coping motives, whereas emotional and physical abuse were positively associated with pain motives, and sexual abuse was positively associated with sleep motives. Using cannabis for coping and increasing attention/focus were also positively associated with higher problematic use, whereas using cannabis for sleep was inversely associated with problematic use one year later. Conclusions: The motives of coping with distress and inattention may represent intermediate constructs through which trauma leads to later problematic cannabis use. Results highlight the need to clarify the pathways between health and non-health-oriented motives and cannabis use over time.

Changes in Medical Cannabis Patient Status before and after Cannabis Legalization in California: Associations with Cannabis and Other Drug Use.

It is unknown how patterns of cannabis and other drug use changed among young adult cannabis users as they became, exited or stayed medical cannabis patients (MCPs) after California legalized cannabis for adult use in 2016. A cohort of 18-26 year-old cannabis users was recruited in Los Angeles in 2014-15 (64.8% male; 44.1% Hispanic/Latinx). Based on wave 1 (pre-legalization) and wave 4 (post-legalization) MCP status, four transition groups emerged: MCP, Into MCP, Out of MCP and NPU (non-patient user). Relationships between self-reported medical cannabis use, transition group membership, and cannabis/other drug use outcomes were examined. Changes in cannabis practices were consistent with changes in MCP status. Cannabis days, concentrate use, self-reported medical cannabis use and driving under influence of cannabis were highest among MCP, increased for Into MCP, and decreased for Out of MCP in wave 4. A majority of drug use outcomes decreased significantly by wave 4. Self-reported medical cannabis use was associated with more frequent cannabis use but less problematic cannabis and other drug use. Future studies should continue to monitor the impact of policies that legalize cannabis for medical or recreational use, and medical motivations for cannabis use on young adults' cannabis and other drug use.

Kids N Fitness Junior: Outcomes of an Evidence-Based Adapted Weight Management Program for Children Ages Three-Seven Years.

Background: Few weight management interventions target young children with obesity from low-income minority families. Objective: To conduct a nonrandomized, pragmatic, pilot study of an adapted, evidence-based, weight management program (Kids N Fitness [KNF]) customized for children ages 3-7 years (Kids N Fitness Jr. [KNF-JR]) on changes in adiposity, nutrition, and physical activity behaviors. Methods: One hundred eighty children (ages 3-16) with ≥85th percentile BMI and their parents participated in one of two 6-week weight management interventions dependent on the child's age: KNF-JR: 3-7 or regular KNF: 8-16. Comparisons were made between baseline anthropometrics and health questionnaire responses, and those from weeks 6 to 18. Two-sample tests for equality of proportions with continuity were used to measure proportions of success between KNF-JR and KNF. Results: At week 6, both cohorts showed a mean decrease in BMI z-score (zBMI) of -0.02 (p = 0.3 for KNF-JR [n = 43]; p = 0.02 for KNF [n = 59], with no significant group differences. Among program completers, 75% of KNF-JR and 83% of KNF maintained or lowered zBMI at week 18 (within-group difference p < 0.01). On average across all participants, at week 18 vs. baseline, improvements occurred in screen time (p < 0.01 KNF-JR, p < 0.02 KNF), sweetened beverage intake (p < 0.01 KNF-JR, p = 0.03 KNF), physical activity (p < 0.01 KNF-JR and KNF), and water (p = 0.01 KNF-JR, non-significant KNF) and vegetable (p < 0.01 KNF-JR, p = 0.02 KNF) consumption. Conclusion: This pilot demonstrated that an evidence-based weight management program can be adapted for all age groups and results in improved BMI status. Larger, randomized controlled trials are needed to verify effectiveness and sustained impact.

Lessons in Adapting a Family-Based Nutrition Program for Children With Autism.

OBJECTIVE: To evaluate the adaptation and implementation of an existing, evidence-based nutrition program for children with autism and their parents. METHODS: Children aged 7-12 years with autism and their parent participated in 6 weekly sessions. Recruitment, intervention, and data collection took place in a community health center in an urban area. RESULTS: Of the 50 referred participants, 38% attended the first classes, and 26% completed the program. Families and staff expressed satisfaction; parents reported increased physical activity, fruit, and vegetable intake in their children. Parents also desired continued learning and individualized recommendations. CONCLUSIONS AND IMPLICATIONS: Adapting family-centered nutrition programs can positively influence diet behaviors in children with autism. As many children with autism battle with obesity, the findings from this pilot provide important insight into supporting these families and can further inform the development of evidence-based practices currently lacking for children with autism and their families.

Hedgehog-Interacting Protein is a multimodal antagonist of Hedgehog signalling.

Hedgehog (HH) morphogen signalling, crucial for cell growth and tissue patterning in animals, is initiated by the binding of dually lipidated HH ligands to cell surface receptors. Hedgehog-Interacting Protein (HHIP), the only reported secreted inhibitor of Sonic Hedgehog (SHH) signalling, binds directly to SHH with high nanomolar affinity, sequestering SHH. Here, we report the structure of the HHIP N-terminal domain (HHIP-N) in complex with a glycosaminoglycan (GAG). HHIP-N displays a unique bipartite fold with a GAG-binding domain alongside a Cysteine Rich Domain (CRD). We show that HHIP-N is required to convey full HHIP inhibitory function, likely by interacting with the cholesterol moiety covalently linked to HH ligands, thereby preventing this SHH-attached cholesterol from binding to the HH receptor Patched (PTCH1). We also present the structure of the HHIP C-terminal domain in complex with the GAG heparin. Heparin can bind to both HHIP-N and HHIP-C, thereby inducing clustering at the cell surface and generating a high-avidity platform for SHH sequestration and inhibition. Our data suggest a multimodal mechanism, in which HHIP can bind two specific sites on the SHH morphogen, alongside multiple GAG interactions, to inhibit SHH signalling.

Attitudes and beliefs about recreational cannabis legalization among cannabis-using young adults in Los Angeles: Impact on concurrent cannabis practices and problematic cannabis use.

BACKGROUND: This study investigated differences in attitudes and beliefs about recreational cannabis legalization (RCL) among cannabis-using young adults comprised of medical cannabis patients (MCP) and non-patient users (NPU). We further investigated whether these variations are associated with concurrent cannabis practices and problematic use. METHOD: Cannabis-using young adults (N = 301) were interviewed between 2017 and 2018 - after RCL and through the early months after storefront sales began. Latent class analysis empirically derived groups based on participants' attitudes/beliefs about the impact of RCL. Socio-demographic factors, patient status, medicinal and/or recreational use, and social norms differentiated latent class memberships, while concurrent cannabis practices and problematic use served as distal outcomes. The manual Bolck, Croon, and Hagenaars (BCH) three-step process modeled all covariates and distal outcomes simultaneously in the final LCA solution. RESULTS: Three patterns emerged: Impacted (RCL had broad impact on attitudes/beliefs) (n = 113), Partially-Impacted (RCL had some impact on attitudes/beliefs) (n = 131) and Neutral (RCL had no/limited impact) (n = 57). MCP were more likely to be Neutral than Partially-Impacted users while those who reported recreational cannabis use were more likely to be Impacted than Neutral users. Class membership predicted cannabis practices and problematic use with Impacted individuals reporting the greatest recent days of use, number of hits per day, and highest scores in problematic cannabis use compared to Partially-Impacted and Neutral users. CONCLUSION: Variability in attitudes/beliefs about RCL served as strong drivers of concurrent cannabis practices and problematic use. Findings provide an important baseline for tracking attitudes/beliefs' long-term health and substance use impact as retail cannabis sales evolve.

Finding MyVOICE: A Mixed-Methods Examination of Health Outcomes of Young Adults with Chronic Illness Transitioning from Pediatric to Adult Health Care.

INTRODUCTION: This study examines health use outcomes of young adults with chronic illness following participation in a transition program and identifies variables that impact outcomes. METHOD: A sample of 119 ethnically diverse, low-income young adults (mean age = 21.8 years) was interviewed 6 months post-transition. Chi-square tests and logistic regression analyses examined the relationship between variables and outcomes. Responses to open-ended questions provided context to findings. RESULTS: Primary care and insurance linkage were significantly higher for patients enrolled in a fully-formed clinic than patients enrolled early in the clinic's development. Patients with multiple diagnoses reported significantly more hospitalizations and specialty care engagement. Hospitalizations and possession of medical records differed significantly by subspecialty. Visit number predicted hospitalizations after accounting for subspecialty, but not after accounting for the number of conditions. DISCUSSION: This study highlights the impact of disease type and severity on post-transition outcomes following participation in a transition program serving socially and medically complex patients.

Pain Profiles among Young Adult Cannabis Users: An Analysis of Antecedent Factors and Distal Outcomes.

BACKGROUND: Pain is a primary reason for medical cannabis use among young adults, however little is known about the patterns of pain in this group. This study identified pain profiles among young adult cannabis users and examined related antecedents and distal outcomes. METHODS: Past 30-day cannabis users aged 18-26, both medical cannabis patients and non-patients, were enrolled in Los Angeles in 2014-2015. A latent class analysis was used to identify pain classes based on history of chronic pain conditions and recent non-minor pain. The study assessed the predictors of membership in pain classes and examined the association of classes with recent mental health characteristics, cannabis use motives and practices. RESULTS: Three classes were identified: Low pain (56.3%), Multiple pain (27.3%), and Nonspecific pain (16.4%). In adjusted models, lifetime insomnia was associated with membership in Multiple pain and Nonspecific pain classes versus the Low pain class. Medical cannabis patients and Hispanics/Latinos were more likely to belong to the Multiple pain class than the other classes. Regarding recent outcomes, the Multiple pain and Nonspecific pain classes were more likely than the Low pain class to use cannabis to relieve physical pain. Additionally, the Multiple pain class had a higher probability of psychological distress, self-reported medical cannabis use, consuming edibles, and using cannabis to sleep compared to one or both other classes. CONCLUSION: Findings suggest that young adult cannabis users can be separated into distinct groups with different pain profiles. The Multiple pain profile was associated with medically-oriented cannabis use motives and practices.

Cannabidiol (CBD) and other drug use among young adults who use cannabis in Los Angeles.

INTRODUCTION: Cannabidiol (CBD) is purportedly a promising therapeutic agent to provide relief for a variety of medical conditions with mild or no psychoactive effects. However, little is known about young adults who use cannabis and CBD-dominant products, and associations between CBD use and other drug use. METHODS: Young adults (aged 24-32) who currently used cannabis (n = 239) were surveyed in Los Angeles in March 2019 through March 2020. The sample was divided into CBD-dominant (at least 1:1 CBD:THC ratio) and THC-dominant product users. We described CBD forms, reasons and conditions for CBD use and examined between-group differences in sociodemographic characteristics, cannabis practices, health and other drug use. RESULTS: CBD-dominant users were more likely to be female, use cannabis at lower frequency and amount (except for edible/drinkable/oral products), self-report medical motivation for cannabis use, use cannabis for pain and report more health problems. Oil, flower, topicals and sprays/drops/tinctures were the most prevalent CBD forms. Psychological problems and pain were commonly reported conditions and medical reasons for CBD use. CBD-dominant users were more likely to report illicit drug use, where psilocybin use was markedly different between the two groups. CONCLUSIONS: CBD use was associated with health histories and motivations linked to pain and psychological problems. Positive association between CBD use and illicit drug use may indicate self-medication for psychological conditions. Future studies should evaluate the effectiveness of various CBD forms and dose regimens for treatment of pain and psychological problems, and as a potential intervention for decreasing other drug use and associated harms.

The Role of Life Events/Contextual Factors and Cannabis Use in Patterns of Other Drug Use Among Young Adult Cannabis Users in Los Angeles: A Qualitative Inquiry.

This analysis examined the role of impactful life events/stressful contextual factors and cannabis use in the patterns of illicit drug use. It utilized semi-structured qualitative interviews with 40 young adult medical cannabis patients and 22 non-patient users collected in Los Angeles during 2014-2015. Three patterns of illicit drug use emerged based on participants' narratives: regular/problematic, recreational/occasional, and never users. Among regular/problematic users, a common theme was the lasting impact of traumatic life events or stressful contextual factors on transition to and away from problematic drug use, and using cannabis to cope with negative after effects of drug use. In contrast, most recreational/occasional and never users, who reported impactful life events or stressful contextual factors, used cannabis to cope with those experiences. Family history of addiction and acceptance of cannabis use within a family as protective factors against illicit drug use among some recreational/occasional and never users was an unexpected finding.

Developmental trajectories of illicit drug use, prescription drug misuse and cannabis practices among young adult cannabis users in Los Angeles.

INTRODUCTION AND AIMS: Young adults have the highest rates of drug use and contribute significantly to the growing population of medical cannabis patients (MCP). This study examined relationships between longitudinal patterns of illicit/prescription drug use/misuse and cannabis practices among young adult cannabis users. DESIGN AND METHODS: In 2014-2015, 210 young adult MCP and 156 nonpatient users were recruited in Los Angeles and surveyed annually over four waves. The analytical sample was limited to completers of all four waves (n = 301). Distinct developmental trajectories of illicit drug use and prescription drug misuse were identified. Fixed effects regression analysis evaluated changes in cannabis practices by trajectory groups. RESULTS: Results supported two-trajectory solutions (high/low) for illicit drug use and prescription drug misuse. Decreases in use within all four trajectories occurred by wave 4. Low illicit drug use trajectory members were more likely to self-report medical cannabis use. Membership in both types of high-use trajectories was associated with use of concentrates and edibles. The prevalence of MCP, edibles use and cannabis days decreased significantly by wave 4. DISCUSSION AND CONCLUSIONS: While alternative cannabis forms use was associated with membership in high drug use trajectories, self-reported medical cannabis use (not MCP) was negatively associated with high illicit drug use trajectory membership. Reductions in the prevalence of MCP, cannabis days, edibles use and other drug use by wave 4 alongside stable levels of self-reported medical cannabis use might reflect the changing legal status of cannabis in California, maturing out phenomenon and safer patterns of cannabis use.