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2/20/2018 Item 13, POSAFY
Purrington, Teresa From:POSAFY <info@posafy.org> Sent:Wednesday, February 14, 2018 1:12 PM To:Harmon, Heidi Cc:Carlos Guerrero; Frank Warren; Zoe Wells; E-mail Council Website; Mila Vujovich-La Barre; Lisa Guy; Timothy Olivas; Staley, Chris; Sharon OGara; Steven Saavedra; Gabriel Granados; Kevin A. Sabet; Lori Robinson; jastadams@gmail.com; SAM (Smart Approaches to Marijuana); Johnson, Derek; Chuck Stevenson; Dominic; John W. Belsher; VSoul@t-mha.org; City_Attorney; Ben Cort; Olson, Garret; Jill Bolster-White; John Calandro; Leslie O'Connor; James Brescia; Cantrell, Deanna; Codron, Michael; Dan Dow; Ian Parkinson; JosephAJohnson; CityClerk; Davidson, Doug; Christine Miller; Catherine Antley, MD; Fowler, Xzandrea; Clark Guest; Penny Borenstein; POSAFY; Carol Rich; Ted Rich; Gomez, Aaron; Dan Rivoire; Pease, Andy; Christianson, Carlyn; jpeschong@co.slo.ca.us; Amy Belsher Subject:SLO Marijuana Dispensaries Attachments:MARIJUANA.VIOLENCE.doc; STUDIES.MARIJUANA.MENTAL.HEALTH.pdf; MARIJUANA.MENTAL.ILLNESS.doc; Arendt -cannabis and suicide in Denmark.pdf; Agrawal - depression and suicidal thoughts.pdf; Clarke, cannabis and suicide, Ireland.pdf; Silins, suicide paper.pdf; STUDIES.MARIJUANA.VIOLENCE.pdf; 2017 Legalization of Marijuana in Colorado The Impact Rich Text.pdf; CRYSTAL.THC.pdf Honorable Mayor: In response to your request to provide “peer reviewed” data regarding the harms of marijuana—and reasons why San Luis Obispo needs to consider not promoting this drug through dispensaries and/or manufacturing. Please see the following links and attachments and note that although peer review is important (and provided), the “anecdotal” data, as well as stats and observations we are receiving from throughout the United States is equally as important, as they are indicators of the on the ground experiences that are occurring widespread—as reported by ER physicians, Mental Health Workers, Psych Hospitals, and other professionals in the field. Additionally, we are seeingnews reports daily of fatal drugged driving accidents with marijuana in the system as well as robberies and murders where marijuana is at issue. The “anecdotal” information, as well as the peer reviewed studies, clearly show the increasing problems we are seeing as a nation due to the proliferation of today’s potent THC-laden marijuana. As you know, peer review means that other professionals concur with the data. This is also true of the reports--not just studies--we are getting, for example, from ER doctors. A group of these doctors are sharing national data on the dramatic increases in ER visits due to: psychosis, CHS (Cannibinoid Hyperemesis Syndrome), poisonings and other marijuana related issues. We are also seeing this right here in our SLO ERs (per our ER doctors). As you are aware, today’s proliferation of potent marijuana is a new phenomenon, which means the studies are just now becoming available—therefore, it is prudent to look at the entire picture when making such huge decisions as to whether or not to bring this drug into our City. Below you will find a cross-reference of information, including “peer reviewed” articles, data gathered by professionals and other reports--all valid when considering SLO’s future. Promoting this drug, allowing dispensaries and allowing manufacturing, all contribute to negative outcomes. Where San Luis Obispo once was a leader in providing a no-smoke haven, we are now considering inviting a new smoke product into our City, along with other dangerous derivatives from the Cannabis plant. Unlike cigarette smoke, this product will not only cause second hand smoke, but also contact high issues, stench and public intoxication. POSAFY urges San Luis Obispo to stand up, stand back and reserve diving into this Cannabis craze—which we know is fueled by dollars more than the consideration of public health consequences. These public health implications are damaging to our youth, our community and would forever change our quality of life here in SLO. We recently heard a speaker at the SLO Planning Commission who freely went on record saying he and his business partners are not from here but are moving here expressly to create marijuana businesses and exploit our town. Along with these individuals, as you will see below, the homelessness in legal states is at epic proportions. San Luis Obispo already has a sizable homeless population. We don’t feel that attracting out of town marijuana 1 businesses and homelessness is a good fit for SLO. And remember too, that cannabis is against Federal law and recent Federal decisions mean that states may be more likely to face penalties for violating Federal law. If SLO is looking to create tax dollars, it is imperative you understand the associated costs and risks to those dollars. There is sufficient data, robust studies, and important anecdotal reports, to cause alarm. The following studies, articles and data address the damaging effects on youth, in addition to other points previously made in the other email (also attached). These studies and articles include reports by neuroscientists, doctors, researchers and other professionals who clearly show, irrefutably, the negative effects of marijuana—particularly on our youth. Today’s marijuana is not the same drug it used to be. Marijuana products—even those at regulated medical dispensaries—are often found to contain harmful pesticides, arsenic, mold, bacteria and other pathogens. Growers are negatively affecting our environment, utilizing enormous amounts of electricity, water and contaminating our streams and lakes with their chemical runoff and other debris. Had the vote legalized marijuana cigarettes—as they once were decades ago at 1-3% THC, then we would have potentially supported the vote. However, this is not the case. And again, if our citizens were properly informed as to what exactly they were voting for, with respect to Prop 64, the vote would most certainly not have been the same. Legalization not only means allowing marijuana joints, it also includes edibles (serious dosing issues and dangers for children and pets), vaping (which studies show is full of harmful chemicals), and concentrates such as dabs, shatter, and glass—which is up to 98% THC (causing a drastic increase in psychosis and addiction). SLO’s mental health providers are already dealing with limited critical mental health services. Marijuana triggered mental illness is a real and present danger to our community. Studies are also now concluding that marijuana primes the brain for other addictions as well, decreases IQ by up to 8 points and lowers education levels, job attainment and quality of life. Cartels have moved into family neighborhoods in Colorado and bought up properties. Safety is another issue, as dispensaries are cash-based businesses and attract crime. We support the potential production and sales of CBD oil, if it conforms to content purity and THC limits of less than 0.3%.CBD appears to be a promising medicine, without causing a neurotoxic effect. Allowing sales of and manufacturing of CBD (not THC) would be a cautious, good first step for San Luis Obispo to consider. We agree that decriminalization is important and no one should be charged solely for marijuana use. However, legalizing today’s marijuana was not necessary to have it decriminalized. Conflating medical marijuana with recreational is also at issue. We also know that adolescents brains develop around age 25 up until age 30. The legal age for marijuana—all products—is 21. This will directly affect our Cal Poly students. We also know that dispensaries contribute to increased youth usage—which will negatively affect our junior high and high school populations. Let’s slow down and think this through before making a huge mistake. POSAFY is on record, to implore you to make the right choice for our City by not allowing dispensaries or manufacturing of THC products. Your legacy as a leader of our City should not be the promotion of a drug and its negative consequences. Respectfully, Jody Belsher President POSAFY Prevention of Substance Abuse for Youth cc: to other community leaders, educators and concerned individuals There are many more papers, articles, reports, studies, etc, and many more to come. Please take your time to review the attached. LIST OF PEER REVIEWED SCIENTIFIC PAPERS Negative Effects of Marijuana http://kgov.com/negative-effects-of-marijuana-pot-research-shows-cannabis-is-harmful ADVERSE HEALTH EFFECTS OF MARIJUANA USAGE 2 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4827335/ White matter damage caused by 'skunk-like' cannabis, study shows https://www.sciencedaily.com/releases/2015/11/151127102333.htm A Review of the Research on the Risks and Harms Associated to the Use of Marijuana http://www.globaldrugpolicy.org/Issues/Vol%203%20Issue%202/Review%20of%20the%20Research.pdf An Evidence Based Review of Acute and Long-Term Effects of Cannabis Use on Executive Cognitive Functions https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3037578/ Marijuana Use: Detrimental to Youth, American College of Pediatricians – April 2017 https://www.acpeds.org/marijuana-use-detrimental-to-youth Environmental Health Effects of Marijuana Cultivation http://www.toxipedia.org/display/toxipedia/Environmental+Health+Effects+of+Marijuana+Cultivation INCREASE OF YOUTH USAGE: https://www.cde.state.co.us/sites/default/files/documents/dropoutprevention/resources/marijuanayouth_slidesp df121911.pdf http://drthurstone.com/federal-study-colorados-mixed-bag-pot/ http://www.washingtonexaminer.com/the-sad-anniversary-of-big-commercial-pot-in-colorado/article/2640413 https://www.denverpost.com/2017/12/22/police-across-colorado-questioning-youth-marijuana- use/#?returnUrl=https://www.denverpost.com/2017/12/22/police-across-colorado-questioning-youth-marijuana- use/?clearUserState=true https://learnaboutsam.org/national-survey-shows-colorado-still-1-state-country-marijuana-use-18-25-year-old- use-rate-skyrocketing/ https://learnaboutsam.org/results-of-legalization/ http://kutv.com/news/local/study-teen-pot-use-increasing-in-colorado-after-legalization/ INCREASE OF BULK MARKETING TO YOUTH: https://www.aspeninstitute.org/blog-posts/are-kids-marketing-target-legal-pot-colorado-public-health-failure/ INCREASE OF ADDICTION: https://learnaboutsam.org/wp-content/uploads/2017/09/27Sep2017-opioids-one-pager.pdf http://www.westword.com/news/colorados-drug-problem-among-usas-worst-study-says-9107629 INCREASE OF MENTAL ILLNESS: https://www.csbj.com/2017/09/15/the-health-effects-of-the-legalization-of-marijuana/ The Clarke paper controlled for a prior history of mood disorders and still found a 7-fold increased risk with marijuana use. The Agrawal paper studied twins to control for genetic confounders (though it was a little difficult to find twins who were completely discordant in their marijuana use) and found a 2.47-fold increase in suicidal thoughts for the twin who used regularly versus the twin who used lightly or not at all. A web site from Colorado - looking at suicide data: https://cohealthviz.dphe.state.co.us/t/HSEBPublic/views/CoVDRS_12_1_17/Story1?:embed=y&:showAppBann er=false&:showShareOptions=true&:display_count=no&:showVizHome=no#4 INCREASE OF ER VISITS: https://www.cbsnews.com/news/pot-legalized-colorado-teens-hospital-er/ http://www.aappublications.org/news/2017/05/04/PASMarijuana050417 INCREASE OF DRUGGED DRIVING: https://www.denverpost.com/2017/08/25/colorado-marijuana-traffic-fatalities/ 3 https://learnaboutsam.org/sam-statement-denver-posts-new-stoned-driving-analysis/ DECREASE OF PROPERTY VALUES: Pueblo, Colorado property values are going up due to cash paying drug dealers, however, cartels are buying up the houses and property, preventing residents from doing so—as we’ve seen in our own neighborhood (Aubree Adams, Pueblo resident). http://www.kktv.com/home/headlines/Call-for-Action-Investigation--Pot-Houses-378320501.html http://rentmedenver.com/detrimental-effects-marijuana-legalization-colorado-real-estate/ https://www.denverite.com/residential-marijuana-grows-new-meth-house-colorado-18560/ INVITES OUTSIDE GROUPS, INCLUDING CARTELS INTO OUR TOWN: https://www.thecannabist.co/2016/01/28/colorado-marijuana-drug-traffickers-black-market-other-states/47334/ http://www.businessinsider.com/ap-drug-traffickers-seek-safe-haven-amid-legal-marijuana-2016-1 http://www.businessinsider.com/ap-drug-traffickers-seek-safe-haven-amid-legal-marijuana-2016-1 INVITES CRIME: http://www.washingtonexaminer.com/colorado-politicians-ignore-major-pot-problems/article/2645486 https://www.denverpost.com/2017/07/11/colorado-sees-big-increase-crime-10-percent-higher-murder-rate/ http://kdvr.com/2017/10/09/4-men-with-ties-to-cuba-arrested-in-illegal-marijuana-grows-in-pueblo/ https://www.chieftain.com/pot_topic/illegal-marijuana-grow-busts-blew-up-in-pueblo-in/article_af4aa09e-5061- 11e6-a99d-abe23d54b20b.html https://www.chieftain.com/news/pueblo/suspects-in-pueblo-shooting-arrested-in-oklahoma- city/article_467d056d-204a-5dca-bb81-984ae487922e.html http://kdvr.com/2016/05/24/prosecutors-colorado-sees-increase-in-murders-motivated-by-marijuana/ They are using cars to traffic drugs. https://www.denverpost.com/2017/07/13/colorado-most-stolen-cars-2017/ https://www.nccpsafety.org/assets/files/library/Legalized_Marijuana_Practical_Guide_for_Law_Enforcement.pd f INCREASES COSTS TO CITY FOR REGULATION AND CONTROL: http://gazette.com/drug-use-a-problem-for-employers/article/1548427 https://learnaboutsam.org/sam-statement-marijuana-industry-report-colorado-marijuana-tax-revenue/ PUTS CITY AT RISK FOR SANCTIONS FOR VIOLATION OF FEDERAL LAW, DECREASES QUALITY OF LIFE: http://www.poppot.org/2018/01/29/sessions-correct-addiction-drug-deaths/ https://www.usatoday.com/story/opinion/2017/08/07/marijuana-devastated-colorado-dont-legalize-nationally- jeff-hunt-column/536010001/ DESTROYS THE ENVIRONMENT: https://www.thedenverchannel.com/news/local-news/illegal-pot-grows-destroying-colorados-national-forests- us-forest-service-says MISC.: RockyMountainHIDTAReportonMarijuana http://www.rmhidta.org/html/FINAL%202017%20Legalization%20of%20Marijuana%20in%20Colorado%20The%20Impa ct.pdf See page 130 from Rocky Mtn HIDTA 2017 report Go to "Methods, Circumstances and Toxicology" page, then sort for ages 10 - 19 yo, pick time frame from 2009 (when medical mj sales started) to 2015 (most recent yr data available) Results: marijuana present - 18%, alcohol present - 11%, opiates present - 6.4% https://soundcloud.com/kcrw/smells-like-skunk-carpinteria-greenhouses-turn-to-pot http://www.stoppot.org/2017/10/02/stop-calling-life-saving-medicine-start-feds-crackdown/ 4 MARIJUANAANDVIOLENCE: 11/17 Kevin Neal a pot farmer in N Cal shot his neighbors then went on a rampage in Red Bluff, CA shooting and killing 4 and ting 14 total people including children at a school. http://www.stoppot.org/2017/11/21/marijuanaviolencerecentmassshootings/ 11/17: Devin Patrick Kelly had criminal arrest for marijuana possession in 2013 following court-martial from Air Force in 2012 following assaulting his spouse and child, shot 36 people – killing 26 at the First Baptist Church in Sutherland Springs, TX 5/17: Salman Abedi the Manchester England bomber had calls about his erratic behaviour made around five years before the bombing to Police after Abedi left school, where he was known to have smoked marijuana and mixed with gangs in south Manchester. 5/17: Richard Rojas was a troubled man with a history of drunken driving bolted from his maroon Honda Accord after his deadly midday rampage in Times Square that left one person dead and 20 others injured. He later told another officer, "I smoked marijuana. I laced the marijuana with PCP," according to the complaint. 9/16: WA Cascade Mall Shooter Arcan Cetin blamed cannabis for his behavior 6/16: Omar Mateen Orlando night club shooter admitted to using marijuana and steroids 11/15: Robert Dear Planned Parenthood gunman in Colorado moved to CO from North Carolina for marijuana 11/15: Brahim Abdeslam Paris bomber was known marijuana dealer from his café in Molenbeek Brussels 8/15: Jody Herring, mother on THC pills for pain, shot and killed Vermont Social worker and 2 others 7/15: Chattanooga TN shooter Mohammad Abdulazeez killed 4 Marines and a sailor, was a heavy user of marijuana 6/15: Dylnn Roof shoots 9 parishioners dead in Charleston, South Carolina, was an admitted marijuana user with schizophrenia 4/14: Richard Kirk, Colorado father of 3, shoots his wife in the head while she is talking to the 911 operator after eating marijuana laced candy. 1/14: Mall in Columbia (MD) shooter marijuana user Darion Aguilar killed 2 and then himself 4/13: Boston Marathon bombing, both Tsarnaev brothers were heavy marijuana users. 12/12: Jacob T Roberts in Clackamas Town Center OR killed 2 seriously injured 1 and then killed himself a chronic marijuana since age 16 7/12: Aurora, Colorado theater shooter, James Holmes, was reported to be a marijuana user. 1/11: Tuscon Massacre convict Jared Loughner was a habitual pot user 3/10: Pentagon shooter John Bedell's history of mental illness and marijuana abuse 5 www.posafy.org info@posafy.org https://twitter.com/POSAFYorg https://www.facebook.com/POSAFY/ Mieux vaut prévenir que guérir It’s better to prevent than to heal. PREVIOUSEMAILEXCHANGE: OnFeb2,2018,at7:12PM,POSAFY<info@posafy.org>wrote: HonorableMayor, ThankyouforyourinquiryforadditionaldataonwhydispensariesarenotgoodforourCity.Wewill gladlysendyouproofofeverythingweƭƷğƷĻΓŅƚƩtherecord.Andlettherecordbeclearifyoushould makethemistakeofapprovingdispensariesthattheseforewarningsofwhattoexpectforourCityare herebypubliclystated. Wecareaboutouryouth,ourcommunitiesandourCityandhopethatyouwilltakethetimeto understandtheimplicationsofmarijuanagrowth,developmentanddispensariesinSanLuisObispo. Pleasereadandwatchallofthelinksthatwehavesenttoyou. Hopefullyyouwillbetterunderstandtheseissues. JodyBelsher President POSAFY www.posafy.org 6 info@posafy.org https://twitter.com/POSAFYorg https://www.facebook.com/POSAFY/ <POSAFYweb.jpg> Mieux vaut prévenir que guérir It’s better to prevent than to heal. FROMMAYORHARMON(MAYOROFSLOCITY) OnFeb2,2018,at6:51PM,Harmon,Heidi<hharmon@slocity.org>wrote: Pleasesendpeerrevieweddataforallofyourclaims.Notjustanecdotalstories. From:POSAFY<info@posafy.org> Sent:Friday,February2,20182:45PM To:EmailCouncilWebsite;ChuckStevenson;Codron,Michael;Cantrell,Deanna; Dominic;City_Attorney;Johnson,Derek;Olson,Garret Cc:JohnW.Belsher;CarlosGuerrero;FrankWarren;ZoeWells;MilaVujovichLaBarre; LisaGuy;TimothyOlivas;Staley,Chris;POSAFY;SharonOGara;StevenSaavedra;Gabriel Granados Subject:SLOMarijuanaDispensaries DearEsteemedCityLeadersandfriends, AsyouareabouttomakeaverycriticaldecisiononFebruary20,onwhetheror nottoallowcannabisdispensariesinSanLuisObispo,pleasecontinuetoreview thecurrentinformationthatshould,attheveryleast,haveyoutakeastepback andgomuchmuchslowerwiththisdecision.Thisdecisionhasveryserious implicationsforouryouth,ourcommunityandourhealthasacity.Pleaseslow down,waittoseewhathappensatleastoneyearfromnowandthenmakeyour decisionbasedonthoseoutcomes.Wewerehopingtohaveavoiceatthe PlanningCommission,however,weweredisappointedtolearnithadbeen removedfromtheirğŭĻƓķğΓƌĻğǝźƓŭthecommunitywithouttheopportunityto giveinputandunabletoadequatelypresentourfindingsinthatforum. hǒƷĭƚƒĻƭΓĻƭƷğĬƌźƭŷĻķbycurrentlegalizedstates Dispensaries: increaseyouthusage. increasebulkmarketingtoyouth. increaseaddiction. increasementalillnesses. IncreaseERvisits increasedruggeddriving. decreasepropertyvalues. inviteoutsidegroups,includingcartels,intoourtown. invitecrime. decreasesafety. IncreasecoststoCityforregulationandcontrol. PutCityatriskforsanctionsforviolationofFederallaw. decreasequalityoflife. 7 Remember,theCityresidentsmayhavevotedpositivelytolegalizemarijuana, butconsider: 1)thisincludesCalPolyƭƷǒķĻƓƷƭΓƓƚƷourpermanentresidents; 2)ifthevotewastakentoday,withtheunderstandingthatnotonlywasaͻƆƚźƓƷͼ gettinglegalized,butalsotheconcentratessuchasdabs,honeyoil,ĬǒƷƷĻƩΓВБі I/ΓǞŷźĭŷisveryharmfulonthedevelopingbrain,andedibles,Iguarantee youthevotewouldbedifferent.Thelackofunderstandingofwhatwasbeing legalizedisproblematicinrelyingonthatvotenumberasagaugetosteamroll aheadwithdispensaries. 3)theagetolegallyuseis21,andweknowthatthebraindevelopsupuntil25 30yearsold.Theselegalconcentratesareparticularlyharmfultothisage groupbeingƒğƩƉĻƷĻķΓǞźƷŷƚǒƷanyeducationonthepermanentmental illnessesandaddictionsweareseeinginrecordnumbersincurrentlegal states. Pleasereviewthefollowing: EMERGENCY VISITS RELATED TO MARIJUANA USE AT COLORADO HOSPITAL QUADRUPLE http://www.aappublications.org/news/2017/05/04/PASMarijuana050417 3THINGSIWISHPARENTSANDTEENSKNEWABOUTPOT https://www.msn.com/enus/health/medical/3thingsiwishparentsΑand teensΑknewaboutpot/arAAv6lOW?ocid=se Surprising truths about legalizing cannabis | Ben Cort | TEDxMileHigh https://www.youtube.com/watch?v=SmqtPaMMVuY WHATVOTERSREALLYMEANWHENTHEYSAYTHEYSUPPORTMARIJUANA LEGALIZATION https://www.washingtonpost.com/news/wonk/wp/2017/12/12/whatvoters reallymeanwhentheysaytheysupportmarijuana legalization/?utm_term=.63e7e8364a3e Right-click or tap and hold here to download pictures. To help protect your privacy, Outlook prevented automatic download of this picture from the Internet. What voters really mean when they say they support ... www.washingtonpost.com The proportion of Americans who express support for marijuana legalization in opinion polls has risen sharply over the past decade from the low 30s to as high as 60 ... 8 TWODEATHSATTRIBUTEDTOMARIJUANAGROW http://www.sanluisobispo.com/news/local/crime/article197233994.html#emlnl =Afternoon_Newsletter Right-click or tap and hold here to download pictures. To help protect your privacy, Outlook prevented automatic download of this picture from the Internet. Two men killed in California Valley; sheriff investigating ... www.sanluisobispo.com San Luis Obispo County sheriffÔs deputies are responding to a report of two men apparently shot to death in California Valley on January 29, 2018. SMARTAPPROACHESTOMARIJUANA(SAM)www.learnaboutsam.org 9 P REPARED B Y: R OCKY M OUNTAIN HIDTA S TRATEGIC I NTELLIGENCE U NIT The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Table of Contents Executive Summary ............................................................................................ 1 Purpose ..................................................................................................................................1 Introduction .......................................................................................................... 7 Purpose ..................................................................................................................................7 The Debate ............................................................................................................................8 Background ...........................................................................................................................8 Preface ....................................................................................................................................8 ...........................................................9 Medical Marijuana 2000-2008 .................................................................................................... 9 Medical Marijuana Commercialization and Expansion 2009-Present ............................... 10 Recreational Marijuana 2013-Present...................................................................................... 11 SECTION 1: Impaired Driving and Fatalities ............................................ 13 Some Findings ....................................................................................................................13 DRAFT Differences in Data Citations ............................................................................................14 Definitions by Rocky Mountain HIDTA ........................................................................14 Data for Traffic Deaths ......................................................................................................15 Total Number of Statewide Traffic Deaths ........................................................................... 15 Traffic Deaths Related to Marijuana When a Driver Tested Positive for Marijuana ..... 16 Percent of All Traffic Deaths that were Marijuana-Related when a Driver Tested Positive for Marijuana ............................................................................................................................ 17 Average Number of Traffic Deaths Related to Marijuana when a Driver Tested Positive for Marijuana ............................................................................................................................ 18 Drug Combinations for Drivers who Tested Positive for Marijuana, 2016 .................... 18 Traffic Deaths Related to Marijuana When an Operator Tested Positive for Marijuana.19 Percent of All Traffic Deaths that were Marijuana-Related when an Operator Tested Positive for Marijuana ............................................................................................................. 20 Average Number of Traffic Deaths Related to Marijuana when an Operator Tested Positive for Marijuana ............................................................................................................. 21 Drug Combinations for Operators who Tested Positive for Marijuana, 2016 ................. 21 Data for Impaired Driving ................................................................................................22 Number of Positive Cannabinoid Screens ............................................................................ 22 ChemaTox and Colorado Department of Public Health and Environment (Data Combined 2009-2013) ........................................................................................................ 23 ChemaTox Data Only (2013-May2016) ................................................................................. 23 Table of Contents Page | i The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Colorado State Patrol Number of Drivers Under the Influence of Drugs (DUIDs) ....... 24 Marijuana as a Percent of All DUI and DUIDs .................................................................... 25 Denver Police Department Percent of DUIDs Involving Marijuana ................................ 26 ........................ 26 Total Number of Accidents in Colorado .............................................................................. 27 Related Costs ......................................................................................................................27 Case Examples ....................................................................................................................28 Sources .................................................................................................................................31 SECTION 2: Youth Marijuana Use ............................................................... 33 Some Findings ....................................................................................................................33 Surveys NOT Utilized .......................................................................................................33 Healthy Kids Colorado Survey (HKCS) ............................................................................... 33 Current Marijuana Use for High School and Middle School Students in Colorado.34 Monitoring the Future (MTF) Study ..................................................................................... 35 Centers for Disease Control Youth Risk Behavior Survey (YRBS) ................................... 35 2015 YRBS Participation Map .......................................................................................... 35 Use Data ..............................................................................................................................36 Youth Ages 12 to 17 Years Old ............................................................................................... 36 Average Past Month Use of Marijuana Youth Ages 12 to 17 Years Old .................... 36 Past Month Marijuana Use Youth Ages 12 to 17 Years Old ........................................ 36 DRAFT Prevalence of Past 30-Day Marijuana Use Youth Ages 12 to 17 Years Old ............... 37 Past Month Usage, 12 to 17 Years Old, 2014/2015......................................................... 38 Average Past Month Use Youth Ages 12 to 17 Years Old, 2014/2015 ........................ 39 Past Month Marijuana Use Youth Ages 12 to 17 Years Old, 2014/2015 ..................... 39 Colorado Probation Percent of All Urinalysis Tests Positive for Marijuana Youth Ages 10 to 17 Years Old ........................................................................................ 40 School Data .........................................................................................................................41 Impact on School Violation Numbers ................................................................................... 41 All Drug Violations, 2015-2016 School Year .................................................................. 41 Drug-Related Suspensions/Expulsions .......................................................................... 42 Percent of Total Referrals to Law Enforcement in Colorado....................................... 42 Number of Reported School Dropouts ........................................................................... 43 Colorado School Resource Officer Survey .....................................................................43 Impact on Marijuana-Related Incidents, 2017 ...................................................................... 44 Predominant Marijuana Violations, 2017 ............................................................................. 44 Student Marijuana Source, 2017 ............................................................................................. 45 School Counselor Survey ..................................................................................................45 Impact on Marijuana-Related Incidents, 2015 ...................................................................... 46 Predominant Marijuana Violations, 2015 ............................................................................. 46 Student Marijuana Source, 2015 ............................................................................................. 47 Case Examples ....................................................................................................................47 Table of Contents Page | ii The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Some Comments from School Resource Officers ................................................................ 49 Some Comments from School Counselors ........................................................................... 51 Sources .................................................................................................................................53 SECTION 3: Adult Marijuana Use ............................................................... 55 Some Findings ....................................................................................................................55 Use Data ..............................................................................................................................56 College Age 18 to 25 Years Old .............................................................................................. 56 Average Past Month Use of Marijuana College Age 18 to 25 Years Old ................... 56 Past Month Marijuana Use College Age 18 to 25 Years Old ....................................... 56 Prevalence of Past 30-Day Marijuana Use College Age 18 to 25 Years Old .............. 57 Past Month Usage, 18 to 25 Years Old, 2014/2015......................................................... 58 Average Past Month Use College Age 18 to 25 Years Old, 2014/2015 ....................... 59 Past Month Marijuana Use College Age 18 to 25 Years Old, 2014/2015 .................... 59 Adults Age 26+ Years Old ....................................................................................................... 60 Average Past Month Use of Marijuana College Ages 26+ Years Old......................... 60 Past Month Marijuana Use Adults Age 26+ Years Old ................................................ 60 Prevalence of Past 30-Day Marijuana Use College Adults Age 26+ Years Old ........ 61 Past Month Usage, 26+ Years Old, 2014/2015 ................................................................ 62 Average Past Month Use Adults Ages 26+ Years Old, 2014/2015 .............................. 63 Past Month Marijuana Use Adults Ages 26+ Years Old, 2014/2015 ........................... 63 DRAFT Colorado Adult Marijuana Use Demographics ................................................................... 64 Case Examples ....................................................................................................................64 Sources .................................................................................................................................66 SECTION 4: Emergency Department and Hospital Marijuana-Related Admissions ................................................................................ 67 Some Findings ....................................................................................................................67 Definitions ...........................................................................................................................68 Emergency Department Data ...........................................................................................68 Colorado Department of Public Health and Environment ................................................ 68 Average Emergency Department Rates Related to Marijuana ................................... 69 Emergency Department Rates Related to Marijuana ................................................... 70 Emergency Department Visits Related to Marijuana ................................................... 71 Hospitalization Data ..........................................................................................................72 Colorado Department of Public Health and Environment ................................................ 72 Average Hospitalization Rates Related to Marijuana .................................................. 72 Hospitalization Rates Related to Marijuana .................................................................. 73 Average Hospitalizations Related to Marijuana ........................................................... 74 Hospitalizations Related to Marijuana ........................................................................... 74 Additional Sources................................................................................................................... 75 Table of Contents Page | iii The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 ng Children Under 9 Years Old ...... 75 Cost ......................................................................................................................................75 Case Examples ....................................................................................................................76 Sources .................................................................................................................................80 SECTION 5: Marijuana-Related Exposure ................................................. 81 Some Findings ....................................................................................................................81 Definitions ...........................................................................................................................81 Data ......................................................................................................................................82 Average Number of Marijuana-Related Exposures, All Ages ........................................... 82 Marijuana-Related Exposures ................................................................................................ 82 Marijuana-Related Exposures by Age Range ...................................................................... 83 Average Percent of All Marijuana-Related Exposures, Children Ages 0 to 5 Years Old ........................................................................................................................ 83 Number of Marijuana Only Exposures Reported ............................................................... 84 Case Examples ....................................................................................................................84 Sources .................................................................................................................................85 SECTION 6: Treatment ................................................................................... 87 Some Findings ....................................................................................................................87 DRAFT Data ......................................................................................................................................87 Treatment with Marijuana as Primary Substance Abuse, All Ages ................................. 87 Drug Type for Treatment Admissions, All Ages ................................................................. 88 Percent of Marijuana Treatment Admissions by Age Group ............................................ 89 Marijuana Treatment Admissions Based on Criminal Justice Referrals .......................... 90 Comments from Colorado Treatment Providers ..........................................................90 Case Examples ....................................................................................................................91 Sources .................................................................................................................................92 SECTION 7: Diversion of Colorado Marijuana ......................................... 93 Some Findings ....................................................................................................................93 Definitions ...........................................................................................................................94 Data on Marijuana Investigations ...................................................................................95 RMHIDTA Colorado Task Forces: Marijuana Investigation Seizures.............................. 95 RMHIDTA Colorado Task Forces: Marijuana Investigative Plant Seizures .................... 96 RMHIDTA Colorado Task Forces: Marijuana Investigative Felony Arrests ................... 96 Data on Highway Interdictions .......................................................................................97 Average Colorado Marijuana Interdiction Seizures ........................................................... 97 Colorado Marijuana Interdiction Seizures ........................................................................... 98 Average Pounds of Colorado Marijuana from Interdiction Seizures ............................... 98 States to Which Colorado Marijuana Was Destined, 2016 ................................................. 99 Table of Contents Page | iv The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Top Three Cities for Marijuana Origin ................................................................................. 99 Case Examples of Investigations ...................................................................................100 Case Examples of Interdictions ......................................................................................103 Sources ...............................................................................................................................107 SECTION 8: Diversion by Parcel ................................................................ 109 Some Findings ..................................................................................................................109 Data from U.S. Postal Service .........................................................................................109 Average Number of Parcels Containing Marijuana Mailed from Colorado to Another State .......................................................................................................................................... 109 Parcels Containing Marijuana Mailed from Colorado to Another State ........................ 110 Average Pounds of Colorado Marijuana Seized by the U.S. Postal Inspection Service ...................................................................................................................................... 110 Pounds of Colorado Marijuana Seized by the U.S. Postal Inspection Service .............. 111 Number of States Destined to Receive Marijuana Mailed from Colorado .................... 111 Private Parcel Companies ...............................................................................................112 Case Examples ..................................................................................................................113 Sources ...............................................................................................................................115 SECTION 9: Related Data ............................................................................ 117 DRAFT Topics .................................................................................................................................117 Some Findings ..................................................................................................................117 Crime .................................................................................................................................118 Colorado Crime ...................................................................................................................... 118 City and County of Denver Crime ...................................................................................... 119 Crime in Denver ..................................................................................................................... 120 Denver Police Department Unlawful Public Display/Consumption of Marijuana ...... 120 Boulder Police Department Marijuana Public Consumption Citations ......................... 121 Case Examples ........................................................................................................................ 121 Revenue .............................................................................................................................124 Statewide Budget, Fiscal Year 2017 ................................................................. 124 Total State Revenue from Marijuana Taxes, Calendar Year 2016 ................................... 124 Case Example.......................................................................................................................... 125 Eve ..................................................................................126 Negative Meeting Planner Perceptions, 2014..................................................................... 126 Homeless ...........................................................................................................................128 Suicide Data ......................................................................................................................130 Average Toxicology of Suicides Among Adolescents Ages 10 to 19 Years Old (With Known Toxicology) ......................................................................................................130 Average Toxicology Results by Age Group, 2013-2015 ...............................................131 THC Potency .....................................................................................................................132 Table of Contents Page | v The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 National Average THC Potency Submitted Cannabis Samples ...................................... 132 National Average THC Potency Submitted Hash Oil Samples....................................... 133 Alcohol Consumption .....................................................................................................134 Colorado Average Consumption of Alcohol ..................................................................... 134 Colorado Consumption of Alcohol ..................................................................................... 134 Medical Marijuana Registry ...........................................................................................135 Percent of Medical Marijuana Patients Based on Reporting Conditions, 2016 ............. 136 st Colorado Licensed Marijuana Businesses as of August 1, 2017 ..............................137 Business Comparisons, June 2017 ..................................................................................137 Colorado Business Comparisons, June 2017 ...................................................................... 137 Demand and Market Size ...............................................................................................138 Demand ................................................................................................................................... 138 Market Size ............................................................................................................................. 138 Marijuana Enforcement Division Reported Sales of Marijuana in Colorado..........139 2017 Price of Marijuana ...................................................................................................139 Local Response to Medical and Recreational Marijuana in Colorado .....................140 2016 Local Jurisdiction Licensing Status ............................................................................. 142 Sources ...............................................................................................................................143 SECTION 10: Reference Materials ............................................................. 147 DRAFT Reports and Articles ........................................................................................................147 Impaired Driving ................................................................................................................... 147 Youth Marijuana Use ............................................................................................................. 151 Adult Marijuana Use ............................................................................................................. 152 Emergency Department and Hospital Marijuana-Related Admissions......................... 155 Marijuana-Related Exposure ................................................................................................ 157 Treatment ................................................................................................................................ 157 Related Data ............................................................................................................................ 158 Sources ...............................................................................................................................163 Table of Contents Page | vi The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Executive Summary Purpose Rocky Mountain High Intensity Drug Trafficking Area (RMHIDTA) is tracking the impact of marijuana legalization in the state of Colorado. This report will utilize, whenever possible, a comparison of three different eras in history: 2006 2008: Medical marijuana pre-commercialization era 2009 Present: Medical marijuana commercialization and expansion era 2013 Present: Recreational marijuana era Rocky Mountain HIDTA will collect and report comparative data in a variety of areas, including but not limited to: DRAFT Impaired driving and fatalities Youth marijuana use Adult marijuana use Emergency room admissions Marijuana-related exposure cases Diversion of Colorado marijuana This is the fifth annual report on the impact of legalized marijuana in Colorado. It is divided into ten sections, each providing information on the impact of marijuana legalization. The sections are as follows: Section 1 Impaired Driving and Fatalities: Marijuana-related traffic deaths when a driver was positive for marijuana more than doubled from 55 deaths in 2013 to 123 deaths in 2016. Marijuana-related traffic deaths increased 66 percent in the four-year average (2013-2016) since Colorado legalized recreational marijuana compared to the four-year average (2009-2012) prior to legalization. o During the same time period, all traffic deaths increased 16 percent. Executive Summary Page | 1 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 In 2009, Colorado marijuana-related traffic deaths involving drivers testing positive for marijuana represented 9 percent of all traffic deaths. By 2016, that number has more than doubled to 20 percent. Section 2 Youth Marijuana Use: Youth past month marijuana use increased 12 percent in the three-year average (2013-2015) since Colorado legalized recreational marijuana compared to the three-year average prior to legalization (2010-2012). The latest 2014/2015 results show Colorado youth ranked #1 in the nation for past month marijuana use, up from #4 in 2011/2012 and #14 in 2005/2006. Colorado youth past month marijuana use for 2014/2015 was 55 percent higher than the national average compared to 39 percent higher in 2011/2012. Section 3 Adult Marijuana Use: DRAFT College age past month marijuana use increased 16 percent in the three-year average (2013-2015) since Colorado legalized recreational marijuana compared to the three-year average prior to legalization (2010-2012). The latest 2014/2015 results show Colorado college-age adults ranked #2 in the nation for past-month marijuana use, up from #3 in 2011/2012 and #8 in 2005/2006. Colorado college age past month marijuana use for 2014/2015 was 61 percent higher than the national average compared to 42 percent higher in 2011/2012. Adult past-month marijuana use increased 71 percent in the three-year average (2013-2015) since Colorado legalized recreational marijuana compared to the three-year average prior to legalization (2010-2012). The latest 2014/2015 results show Colorado adults ranked #1 in the nation for past month marijuana use, up from #7 in 2011/2012 and #8 in 2005/2006. Colorado adult past month marijuana use for 2014/2015 was 124 percent higher than the national average compared to 51 percent higher in 2011/2012. Executive Summary Page | 2 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Section 4 Emergency Department and Hospital Marijuana-Related Admissions: The yearly rate of emergency department visits related to marijuana increased 35 percent after the legalization of recreational marijuana (2011-2012 vs. 2013-2015). Number of hospitalizations related to marijuana: o 2011 6,305 o 2012 6,715 o 2013 8,272 o 2014 11,439 o Jan-Sept 2015 10,901 The yearly number of marijuana-related hospitalizations increased 72 percent after the legalization of recreational marijuana (2009-2012 vs. 2013-2015). Section 5 Marijuana-Related Exposure: Marijuana-related exposures increased 139 percen t in the four-year average (2013-2016) since Colorado legalized recreational marijuana compared to the DRAFT four-year average (2009-2012) prior to legalization. Marijuana-Only exposures more than doubled (increased 210 percent) in the four-year average (2013-2016) since Colorado legalized recreational marijuana compared to the four-year average (2009-2012) prior to legalization. Section 6 Treatment: Marijuana treatment data from Colorado in years 2006 2016 does not appear to demonstrate a definitive trend. Colorado averages 6,683 treatment admissions annually for marijuana abuse. Over the last ten years, the top four drugs involved in treatment admissions were alcohol (average 13,551), marijuana (average 6,712), methamphetamine (average 5,578), and heroin (average 3,024). Executive Summary Page | 3 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Section 7 Diversion of Colorado Marijuana: In 2016, RMHIDTA Colorado drug task forces completed 163 investigations of individuals or organizations involved in illegally selling Colorado marijuana both in and out of state. o These cases led to: 252 felony arrests 7,116 (3.5 tons) pounds of marijuana seized 47,108 marijuana plants seized 2,111 marijuana edibles seized 232 pounds of concentrate seized 29 different states to which marijuana was destined Highway interdiction seizures of Colorado marijuana increased 43 percent in the four-year average (2013-2016) since Colorado legalized recreational marijuana compared to the four-year average (2009-2012) prior to legalization. Of the 346 highway interdiction seizures in 2016, there were 36 different states destined to receive marijuana from Colorado. o The most common destinations identified were Illinois, Missouri, Texas, DRAFT Kansas and Florida. Section 8 Diversion by Parcel: Seizures of Colorado marijuana in the U.S. mail has increased 844 percent from an average of 52 parcels (2009-2012) to 491 parcels (2013-2016) in the four-year average that recreational marijuana has been legal. Seizures of Colorado marijuana in the U.S. mail has increased 914 percen t from an average of 97 pounds (2009-2012) to 984 pounds (2013-2016) in the four-year average that recreational marijuana has been legal. Executive Summary Page | 4 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Section 9 Related Data: Crime in Denver increased 17 percent and crime in Colorado increased 11 percent from 2013 to 2016. Colorado annual tax revenue from the sale of recreational and medical marijuana was 0.8 percent 2016). As of June 2017, there were 491 retail marijuana stores in the state of Colorado compared to 392 Starbucks and . 66 percent of local jurisdictions have banned medical and recreational marijuana businesses. Section 10 Reference Materials: This section lists various studies and reports regarding marijuana. DRAFT T HERE IS MUCH MORE DATA IN EACH OF THE TEN SECTIONS. T HIS PUBLICATION MAY BE FOUND ON THE R OCKY M OUNTAIN HIDTA WEBSITE; GO TO WWW.RMHIDTA.ORG AND SELECT R EPORTS. Executive Summary Page | 5 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 DRAFT THIS PAGE INTENTIONALLY LEFT BLANK Executive Summary Page | 6 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Introduction Purpose The purpose of this annual report is to document the impact of the legalization of marijuana for medical and recreational use in Colorado. Colorado serves as an experimental lab for the nation to determine the impact of legalizing marijuana. This is an important opportunity to gather and examine meaningful data and identify trends. Citizens and policymakers nationwide may want to delay any decisions on this important issue until there is sufficient and accurate data to make informed decisions. The Debate There is an ongoing debate in this country concerning the impact of legalizing marijuana. Those in favor argue that the benefits of removing prohibition far outweigh the potential negative consequences. Some of the cited benefits include: Eliminate arrests for possession and sale, resulting in fewer people with criminal records and a reduction in the prison population Free up law enforcement resources to target more serious and violent criminals Reduce traffic fatalities since users will switch from alcohol to marijuana, which does not impair driving to the same degree No increase in use, even among youth, because of strict regulations Added revenue generated through taxation Eliminate the black market Those opposed to legalizing marijuana argue that the potential benefits of lifting prohibition pale in comparison to the adverse consequences. Some of the cited consequences include: Increase in marijuana use among youth and young adults Increase in marijuana-impaired driving fatalities Rise in number of marijuana-addicted users in treatment Diversion of marijuana Introduction Page | 7 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Adverse impact and cost of the physical and mental health damage caused by marijuana use The economic cost to society will far outweigh any potential revenue generated Background As of 2016, a number of states have enacted varying degrees of legalized marijuana by permitting medical marijuana and eight permitting recreational marijuana. In 2010, legislation was passed in Colorado that included the licensing of medical marijuana centers (dispensaries), cultivation operations, and manufacturing of marijuana edibles for medical purposes. In November 2012, Colorado voters legalized recreational marijuana allowing individuals to use and possess an ounce of marijuana and grow up to six plants. The amendment also permits licensing marijuana retail stores, cultivation operations, marijuana edible manufacturers, and testing facilities. Washington voters passed a similar measure in 2012. Preface It is important to note that, for purposes of the debate on legalizing marijuana in Colorado, there are three distinct timeframes to consider: the early medical marijuana era (2000-2008), the medical marijuana commercialization era (2009 current) and the recreational marijuana era (2013 current). 2000 2008: In November 2000, Colorado voters passed Amendment 20 which permitted a qualifying patient, and/or caregiver of a patient, to possess up to 2 ounces of marijuana and grow 6 marijuana plants for medical purposes. During that time there were between 1,000 and 4,800 medical marijuana cardholders and no known dispensaries operating in the state. 2009 Current: Beginning in 2009 due to a number of events, marijuana became de facto legalized through the commercialization of the medical marijuana industry. By the end of 2012, there were over 100,000 medical marijuana cardholders and 500 licensed dispensaries operating in Colorado. There were also licensed cultivation operations and edible manufacturers. Introduction Page | 8 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 2013 Current: In November 2012, Colorado voters passed Constitutional Amendment 64 which legalized marijuana for recreational purposes for anyone over the age of 21. The amendment also allowed for licensed marijuana retail stores, cultivation operations and edible manufacturers. Retail marijuana businesses became operational January 1, 2014. Medical Marijuana 2000 2008 In November 2000, Colorado voters passed Amendment 20 which permitted a qualifying patient and/or caregiver of a patient to possess up to 2 ounces of marijuana and grow 6 marijuana plants for medical purposes. Amendment 20 provided for a debilitating medical condition. The system was managed by the Colorado Department of Public Health and Environment (CDPHE), which issued identification cards to patients accepting applications from patients in June 2001. From 2001 2008, there were only 5,993 patient applications received and only 55 percent of those designated a primary caregiver. During that time, the average was three patients per caregiver and there were no known retail stores selling medical marijuana (dispensaries). Dispensaries were not an issue because CDPHE regulations limited a caregiver to no more than five patients. In late 2007, a Denver district j meeting requirement when it set a five-patient-to-one-caregiver ratio and overturned the rule. That opened the door for caregivers to claim an unlimited number of patients for whom they were providing and growing marijuana. Although this decision expanded the parameters, very few initially began operating medical marijuana commercial operations (dispensaries) in fear of prosecution, particularly from the federal government. problems for local prosecutors seeking a conviction for marijuana distribution by caregivers. Many jurisdictions ceased or limited filing those types of cases. Introduction Page | 9 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Medical Marijuana Commercialization and Expansion 2009 Present The dynamics surrounding medical marijuana in Colorado began to change substantially beginning in early 2009. All of these combined factors played a role in the explosion of the medical marijuana industry and number of patients: At a press conference in Santa Ana, California on February 25, 2009, U.S. Attorney General Eric Holder was asked whether raids in California on medical marijuana campaign promise related to medical marijuana. In mid-March 2009, the U.S. Attorney General clarified the position saying that the Department of Justice enforcement policy would be restricted to traffickers who falsely masqueraded as medical dispensaries and used medical marijuana laws as a shield. Beginning in the spring of 2009, Colorado experienced an explosion to over 20,000 new medical marijuana patient applications and the emergence of over 250 medical . One dispensary owner claimed to be a primary caregiver to 1,200 patients. Government took little or no action against these commercial operations. In July 2009, the Colorado Board of Health, after public hearings, voted to keep the t limiting the number of patients a single caregiver could have. They also voted to change the definition of a caregiver to a person that only had to provide medicine to patients, nothing more. On October 19, 2009, U.S. Deputy Attorney General David Ogden provided guidelines for U.S. Attorneys in states that enacted medical marijuana laws. The memo in clear and unambiguous compliance with existing state law providing for the medical By the end of 2009, new patient applications jumped from around 6,000 for the first seven years to an additional 38,000 in just one year. Actual cardholders went from 4,800 in 2008 to 41,000 in 2009. By mid-2010, there were over 900 unlicensed marijuana dispensaries identified by law enforcement. In 2010, law enforcement sought legislation to ban dispensaries and reinstate the one-to-five ratio of caregiver to patient as the model. However, in 2010 the Colorado Introduction Page | 10 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Legislature passed HB-1284 which legalized medical marijuana centers (dispensaries), marijuana cultivation operations, and manufacturers for marijuana edible products. By 2012, there were 532 licensed dispensaries in Colorado and over 108,000 registered patients, 94 percent of which qualified for a card because of severe pain. Recreational Marijuana 2013 Present In November of 2012, Colorado voters passed Amendment 64 which legalized marijuana for recreational use. Amendment 64 allows individuals 21 years or older to grow up to six plants, possess/use 1 ounce or less, and furnish an ounce or less of marijuana if not for the purpose of remuneration. Amendment 64 permits marijuana retail stores, marijuana cultivation sites, marijuana edible manufacturers and marijuana testing sites. The first retail marijuana businesses were licensed and operational in January of 2014. Some individuals have established private cannabis clubs, formed co- ops for large marijuana grow operations, and/or supplied marijuana for no fee other than donations. What has been the impact of commercialized medical marijuana and legalized recreational marijuana on Colorado? Review the report and you decide. NOTES: D ATA, IF AVAILABLE, WILL COMPARE PRE- AND POST-2009 WHEN MEDICAL MARIJUANA BECAME COMMERCIALIZED AND AFTER 2013 WHEN RECREATIONAL MARIJUANA BECAME LEGALIZED. M ULTI-YEAR COMPARISONS ARE GENERALLY BETTER INDICATORS OF TRENDS. O NE-YEAR FLUCTUATIONS DO NOT NECESSARILY REFLECT A NEW TREND. P ERCENTAGE COMPARISONS MAY BE ROUNDED TO THE NEAREST WHOLE NUMBER. P ERCENT CHANGES ADDED TO GRAPHS WERE CALCULATED AND ADDED BY R OCKY M OUNTAIN HIDTA. T HIS REPORT WILL CITE DATASETS WITH TERMS SUCH AS MARIJUANA-RELATED OR TESTED POSITIVE FOR MARIJUANA T HAT DOES NOT NECESSARILY PROVE THAT MARIJUANA WAS THE CAUSE OF THE INCIDENT. Introduction Page | 11 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 THIS PAGE INTENTIONALLY LEFT BLANK Introduction Page | 12 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 SECTION 1: Impaired Driving and Fatalities Some Findings Marijuana-related traffic deaths when a driver tested positive for marijuana more than doubled from 55 deaths in 2013 to 123 deaths in 2016. Marijuana-related traffic deaths increased 66 percent in the four-year average (2013-2016) since Colorado legalized recreational marijuana compared to the four-year average (2009-2012) prior to legalization. o During the same time period, all traffic deaths increased 16 percent. In 2009, Colorado marijuana-related traffic deaths involving drivers testing positive for marijuana represented 9 percent of all traffic deaths. By 2016, that number has more than doubled to 20 percent. Consistent with the past, in 2016, less than half of drivers (44 percent) or operators (48 percent) involved in traffic deaths were tested for drug impairment. The number of toxicology screens positive for marijuana (primarily DUID) increased 63 percent in the four-year average (2013-2016) since Colorado legalized recreational marijuana compared to the four-year average (2009-2012) prior to legalization. The 2016 Colorado State Patrol DUID Program data includes: o 76 percen t (767) of the 1004 DUIDs involved marijuana. o 38 percent (385) of the 1004 DUIDs involved marijuana only. SECTION 2: Youth Marijuana Use Page | 13 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Differences in Data Citations number of drivers identified in fatal crashes who tested positive for marijuana. There were 47 positive drivers in 2013 and 115 positive drivers in 2016, which represents a 145 percent increase. RMHIDTA cites the number of fatalities when a driver tested positive for marijuana. There were 55 fatalities in 2014 and 123 fatalities in 2016 when a driver was positive for marijuana, which represents a 124 percent increase. that use slightly higher figures than those used by RMHIDTA. After careful analysis of complete data obtained from CDOT, RMHIDTA is confident the numbers cited in this report are accurate. Definitions by Rocky Mountain HIDTA Driving Under the Influence of Drugs (DUID): DUID could include alcohol in operate a vehicle was sufficiently impaired that it brought his or her driving to the attention of law enforcement. The erratic driving and the subsequent evidence that the subject was under the influence of marijuana helps confirm the causation factor. Marijuana-Related: in the toxicology report. It could be marijuana only or marijuana with other drugs and/or alcohol. Marijuana Only: When toxicology results show marijuana and no other drugs or alcohol. Fatalities: Any death resulting from a traffic crash involving a motor vehicle. Operators: Anyone in control of their own movements such as a driver, pedestrian or bicyclist. Drivers: An occupant who is in physical control of a transport vehicle. For an out-of- control vehicle, an occupant who was in control until control was lost. Personal Conveyance: Non-motorized transport devices such as skateboards, wheelchairs (including motorized wheelchairs), tricycles, foot scooters, and Segways. These are more or less non-street legal transport devices. SECTION 2: Youth Marijuana Use Page | 14 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Data for Traffic Deaths NOTE: T HE DATA FOR 2012 THROUGH 2015 WAS OBTAINED FROM THE C OLORADO D EPARTMENT OF T RANSPORTATION (CDOT). CDOT AND RMHIDTA CONTACTED CORONER OFFICES AND LAW ENFORCEMENT AGENCIES INVESTIGATING FATALITIES TO OBTAIN TOXICOLOGY REPORTS. T HIS REPRESENTS 100 PERCENT REPORTING. P RIOR YEAR(S) MAY HAVE HAD LESS THAN 100 PERCENT REPORTING TO THE C OLORADO D EPARTMENT OF T RANSPORTATION, AND SUBSEQUENTLY THE F ATALITY A NALYSIS R EPORTING S YSTEM (FARS). A NALYSIS OF DATA WAS CONDUCTED BY R OCKY M OUNTAIN HIDTA. 2016 FARS DATA WILL NOT BE OFFICIAL UNTIL J ANUARY 2018. Total Number of Statewide Traffic Deaths 800 700 608 554 548 600 535 s 547 h t 488 481 472 a 465 450 e 447 500 D f o r 400 e b m 300 u N 200 100 0 20062007200820092010201120122013201420152016 SOURCE: National Highway Traffic Safety Administration, Fatality Analysis Reporting System (FARS) and Colorado Department of Transportation In 2016 there were a total of 608 traffic deaths of which: o 390 were drivers o 116 were passengers o 79 were pedestrians o 16 were bicyclists o 5 were in personal conveyance o 2 had an unknown position in the vehicle SECTION 2: Youth Marijuana Use Page | 15 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Traffic Deaths Related to Marijuana When a DRIVER Tested Positive for Marijuana Fatalities with Total Statewide Percentage Total Crash Year Drivers Testing Positive Fatalities Fatalities for Marijuana 2006 535 33 6.17% 2007 554 32 5.78% 2008 548 36 6.57% 2009 465 41 8.82% 2010 450 46 10.22% 2011 447 58 12.98% 2012 472 65 13.77% 2013 481 55 11.43% 2014 488 75 15.37% 2015 547 98 17.92% 2016 608 123 20.23% SOURCE: National Highway Traffic Safety Administration, Fatality Analysis Reporting System (FARS), 2006-2011 and Colorado Department of Transportation 2012-2016 In 2016 there were a total of 123 marijuana-related traffic deaths when a driver tested positive for marijuana. Of which: o 100 were drivers o 19 were passengers o 2 were pedestrians o 2 were bicyclists s who tested positive for marijuana use, 71 were found to have Delta 9 tetrahydrocannabinol, or THC, the psychoactive ingredient in marijuana, in their blood, indicating use within hours, according to state data. Of those, 63 percent were over 5 nanograms per 1 SECTION 2: Youth Marijuana Use Page | 16 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Traffic Deaths Related to Marijuana when a DriverTested Positive for Marijuana 140 123 Legalization 120 Commercialization 98 100 75 80 65 58 55 60 46 41 36 33 32 40 20 0 20062007200820092010201120122013201420152016 SOURCE: National Highway Traffic Safety Administration, Fatality Analysis Reporting System (FARS), 2006-2011 and Colorado Department of Transportation 2012-2016 Percent of All Traffic Deaths that were Marijuana-Related when a DriverTested Positive for Marijuana 25.00% Legalization 20.23% 20.00% 17.92% Commercialization 15.37% 13.77% 15.00% 12.98% 11.43% 10.22% 8.82% 10.00% 6.57% 6.17% 5.78% 5.00% 0.00% 20062007200820092010201120122013201420152016 SOURCE: National Highway Traffic Safety Administration, Fatality Analysis Reporting System (FARS), 2006-2011 and Colorado Department of Transportation 2012-2016 SECTION 2: Youth Marijuana Use Page | 17 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Average Number of Traffic Deaths Related to Marijuana when a DriverTested Positive for Marijuana 88 100 80 53 60 34 40 20 56% Increase 66% Increase 0 2006-20082009-20122013-2016 Pre-CommercializationPost-CommercializationLegalization SOURCE: National Highway Traffic Safety Administration, Fatality Analysis Reporting System (FARS), 2006-2011 and Colorado Department of Transportation 2012-2016 Drug Combinations for Driverswho Tested Positive for Marijuana*, 2016 Marijuana Only 21% 7% Marijuana and Alcohol 36% Marijuana and Other Drugs 36% (No Alcohol) Marijuana, Other Drugs and Alcohol *Toxicologyresults for all substances present in individuals who tested positive for marijuana SOURCE: National Highway Traffic Safety Administration, Fatality Analysis Reporting System (FARS), 2006-2011 and Colorado Department of Transportation 2012-2016 SECTION 2: Youth Marijuana Use Page | 18 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Traffic Deaths Related to Marijuana* When an OPERATOR Tested Positive for Marijuana Fatalities with Total Statewide Percent of Total Crash Year Operators Testing Fatalities Fatalities Positive for Marijuana 2006 535 37 6.92% 2007 554 39 7.04% 2008 548 43 7.85% 2009 465 47 10.10% 2010 450 49 10.89% 2011 447 63 14.09% 2012 472 78 16.53% 2013 481 71 14.76% 2014 488 94 19.26% 2015 547 115 21.02% 2016 608 147 24.18% SOURCE: National Highway Traffic Safety Administration, Fatality Analysis Reporting System (FARS), 2006-2011 and Colorado Department of Transportation 2012-2016 In 2016 there were a total of 147 marijuana-related traffic deaths of which: o 100 were drivers o 19 were passengers o 21 were pedestrians o 7 were bicyclists SECTION 2: Youth Marijuana Use Page | 19 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Traffic Deaths Related to Marijuana when an OperatorTested Positive for Marijuana 160 147 140 115 120 s h t 94 Commercialization a 100 e D 78 f 71 o 80 63 r e b 49 47 60 43 m 39 u 37 N 40 Legalization 20 0 20062007200820092010201120122013201420152016 SOURCE: National Highway Traffic Safety Administration, Fatality Analysis Reporting System (FARS), 2006-2011 and Colorado Department of Transportation 2012-2016 Percent of All Traffic Deaths that were Marijuana-Related when an OperatorTested Positive for Marijuana 30.00% 24.18% Commercialization 25.00% 21.02% s h 19.26% t a 20.00% e 16.53% D 14.76% f 14.09% o 15.00% t n 10.89% e 10.10% c r e 7.85% 10.00% 7.04% 6.92% P 5.00% Legalization 0.00% 20062007200820092010201120122013201420152016 SOURCE: National Highway Traffic Safety Administration, Fatality Analysis Reporting System (FARS), 2006-2011 and Colorado Department of Transportation 2012-2016 SECTION 2: Youth Marijuana Use Page | 20 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Average Number of Traffic Deaths Related to Marijuana when an OperatorTested Positive for Marijuana 107 120 100 59 80 40 60 40 20 48% Increase81% Increase 0 2006-20082009-20122013-2016 Pre-CommercializationPost-CommercializationLegalization SOURCE: National Highway Traffic Safety Administration, Fatality Analysis Reporting System (FARS), 2006-2011 and Colorado Department of Transportation 2012-2016 Drug Combinations for Operatorswho Tested Positive for Marijuana*, 2016 Marijuana Only 23% 7% 35% Marijuana and Alcohol Marijuana and Other Drugs 35% (No Alcohol) Marijuana, Other Drugs and Alcohol *Toxicologyresults for all substances present in individuals who tested positive for marijuana SOURCE: National Highway Traffic Safety Administration, Fatality Analysis Reporting System (FARS), 2006-2011 and Colorado Department of Transportation 2012-2016 SECTION 2: Youth Marijuana Use Page | 21 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Data for Impaired Driving NOTE: I F SOMEONE IS DRIVING INTOXICATED FROM ALCOHOL AND UNDER THE INFLUENCE OF ANY OTHER DRUG (INCLUDING MARIJUANA), ALCOHOL IS ALMOST ALWAYS THE ONLY INTOXICANT TESTED FOR. W HETHER OR NOT HE OR SHE IS POSITIVE FOR OTHER DRUGS WILL REMAIN UNKNOWN BECAUSE OTHER DRUGS ARE NOT OFTEN TESTED. Number of Positive Cannabinoid Screens CDPHE and ChemaTox*ChemaToxCBI** 3,500 3,000 1,395 522 2,500 2,000 1,5002,853 2,513 2,430 2,392 2,352 2,034 1,000 1,629 500 787 0 20092010201120122013201420152016 *Data from theColorado Department of Public Health and Environment was merged with ChemaTox data from 2009 to 2013. CDPHE discontinued testing in July 2013. **The Colorado Bureau of Investigation began toxicology operations in July 1, 2015. SOURCE: Colorado Bureau of Investigation and Rocky Mountain HIDTA The state laboratory. NOTE: T HE ABOVE GRAPHS INCLUDE DATA FROM C HEMA T OX L ABORATORY WHICH WAS MERGED WITH DATA SUPPLIED BY C OLORADO D EPARTMENT OF P UBLIC H EALTH AND E NVIRONMENT - T OXICOLOGY L ABORATORY. T HE VAST MAJORITY OF THE SCREENS ARE DUID SUBMISSIONS FROM C OLORADO LAW ENFORCEMENT. NOTE: C OLORADO D EPARTMENT OF P UBLIC H EALTH AND E NVIRONMENT DISCONTINUED TESTING IN J ULY 2013. T HE C OLORADO B UREAU OF I NVESTIGATION B EGAN T ESTING ON J ULY 1, 2015. SECTION 2: Youth Marijuana Use Page | 22 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 ChemaTox and Colorado Department of Public Health and Environment (Data Combined 2009-2013) SOURCE: Sarah Urfer, M.S., D-ABFT-FT; ChemaTox Laboratory ChemaTox Data Only (2013-August 2017) SOURCE: Sarah Urfer, M.D., D-ABFT-FT, ChemaTox Laboratory SECTION 2: Youth Marijuana Use Page | 23 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Colorado State Patrol Number of Drivers Under the Influence of Drugs (DUIDs) 201420152016 1200 1004 874 1000 842 767 674641 800 600 385 354 333 400 200 0 Marijuana OnlyInvolving MarijunaAll DUIDs SOURCE: Colorado State Patrol, CSP Citations for Drug Impairment by Drug Type In 2016, 76 percent of total DUIDs involved marijuana and 38 percent of total DUIDs involved marijuana only SECTION 2: Youth Marijuana Use Page | 24 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Marijuana as a Percent of All DUI and DUIDs* 17.2% 18.0% 13.4% 16.0% 12.2% 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 10% Increase 28% Increase 0.0% 201420152016 *Driving Under the Influenceof Alcohol and Driving Under the Influence of Drugs SOURCE: Colorado State Patrol, CSP Citations for Drug Impairment by Drug Type In 2016, Colorado State Patrol made about 300 fewer DUI and DUID cases than in 2015. However, marijuana made up 17 percent of the total in 2016 compared to 13 percent of the total in 2015 and 12 percent of the total in 2014. NOTE: ARIJUANA CITATIONS DEFINED AS ANY CITATION WHERE CONTACT WAS CITED FOR D RIVING U NDER THE I NFLUENCE (DUI) OR D RIVING W HILE A BILITY I MPAIRED (DWAI) AND MARIJUANA INFORMATION WAS FILLED OUT ON TRAFFIC STOP FORM INDICATING MARIJUANA & ALCOHOL, MARIJUANA & OTHER CONTROLLED SUBSTANCES, OR MARIJUANA ONLY PRESENT BASED ON OFFICER OPINION ONLY (NO TOXICOLOGICAL CONFIRMATION - C OLORADO S TATE P ATROL SECTION 2: Youth Marijuana Use Page | 25 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Denver Police Department Percent of DUIDs Involving Marijuana 55% 52% 60% 49% 50% 37% 40% 30% 20% 10% 0% 2013201420152016 SOURCE: Denver Police Department, Traffic Operations Bureau via Data Analysis Unit Larimer County Sheriff's Office Percent of DUIDs Involving Marijuana 63% 64% 60% 62% 60% 57% 58% 55% 56% 54% 52% 50% 2013201420152016 SOURCE: Larimer County SECTION 2: Youth Marijuana Use Page | 26 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Total Number of Traffic Accidents in Colorado 160,000 140,000 124,846 120,700 111,899 s t 107,604 120,000 n 101,627 100,994 e d i 117,228 115,455 100,000 c c 104,748 A 100,832 99,011 f 80,000 o r e b 60,000 m u N 40,000 20,000 0 20052006200720082009201020112012201320142015 SOURCE: Colorado Department of Transportation (CDOT) Per CDOT, the total number of traffic accidents in Colorado for 2016 was not NOTE: R OCKY M OUNTAIN HIDTA HAS BEEN ASKED ABOUT THE TOTAL NUMBER OF TRAFFIC ACCIDENTS SEEN IN C OLORADO SINCE LEGALIZATION AND IS, THEREFORE, PROVIDING THE DATA. R OCKY M OUNTAIN HIDTA IS NOT EQUATING ALL TRAFFIC ACCIDENTS WITH MARIJUANA LEGALIZATION. Related Costs Economic Cost of Vehicle Accidents Resulting in Fatalities: According to the National Highway Traffic Safety Administration report, The Economic and Societal Impact of Motor Vehicles Crashes, 2010, the total economic costs for a vehicle fatality is $1,398,916. That includes property damage, medical, insurance, productivity, among other 2 considerations. Cost of Driving Under the Influence: The cost associated with the first driving-under- the-influence (DUI) offense is estimated at $10,270. Costs associated with a DUID 3 (driving-under-the-influence-of-drugs) are very similar to those of a DUI/alcohol. SECTION 2: Youth Marijuana Use Page | 27 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Case Examples Traffic Fatalities Linked to Marijuana are up Sharply in Colorado: Since the legalization of recreational marijuana, the number of fatal accidents involving drivers who pot usage in Colorado since 2013. Many family members and loved ones of victims involved in these fatal accidents are speaking out about the inability for authorities to properly test for impairment. rstanding was killed in 2015 in a collision with a driver who tested positive for marijuana use below the legal limit and charged only with careless On January 13, 2016 just buddy, Jordan Aerts, 18, were joyriding around north Denver in a car they had stolen a few hours earlier. Ripping south along Franklin Street, where it curves hard to the right onto National Western Drive, Gray lost control, drove through a fence and went straight onto the bordering railroad tracks. The car rolled and Gray was ejected. Both autopsy done revealed that her son had 10ng/mL , twice the legal limit, of THC in his system when he died, until the Denver Post contacted her. and out there to drive when t Too little is understood about how marijuana impairs ability to operate a vehicle. Due to this lack of understanding the Denver Post stated who occasionally test for the drug bicker over whether to include pot on Canfield. particularly when you know what it does to your time and depth perception, SECTION 2: Youth Marijuana Use Page | 28 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Colorado now mandates that traffic fatalities within the state be analyzed to see what role drugs played in the crashes. State police are re-analyzing samples from suspected drunk drivers in 2015 and a Denver Post source stated five also tested positive for active THC. 1 departments will stop testing when a driver tests positive for alcohol impairment. 20-Year-Old Colorado Man Kills 8-Year-Old Girl While Driving High: A former star athlete at Mead High School accused of fatally running over an 8-year-old Longmont girl on her bike told police he thought he'd hit the curb until he saw the girl's stepfather waving at him, according to an arrest affidavit released July 29, 2016. Kyle Kenneth Couch, 20, turned right on a red light at the same time Peyton Knowlton rolled into the crosswalk on May 20, 2016. The girl was crushed by the rear right tire of the Ford F-250 pickup, and died from her injuries. Couch, of Longmont, surrendered to police Friday on an arrest warrant that included charges of vehicular homicide and driving under the influence of drugs. One blood sample collected more than two hours after the collision tested positive for cannabinoids, finding 1.5 nanograms of THC per milliliter of blood. That's below Colorado's legal limit of 5 nanograms per milliliter. But Deputy Police Chief Jeff Satur said the law allows the DUI charge when those test results are combined with officer observations of impaired behavior and marijuana evidence found inside Couch's pickup. The presumptive sentencing range for vehicular homicide, a Class 3 felony, is four to 12 years in prison. Couch attends Colorado Mesa University where, in 2015, he appeared in six games as a linebacker as a red shirt freshman for the football team. In 2013, Couch became the first athlete from Mead High School to win a state title when he captured the Class 4A wrestling championship at 182 pounds. He was named the Times-Call's Wrestler of the Year that season and was able to defend his crown a year later, winning the 4A title at 195 pounds to cap his senior season with a 49-1 record. Couch, now 20, has been arrested on suspicion of vehicular homicide and driving under the influence of marijuana in connection with the death of 8-year-old Peyton 4 Knowlton. Valedictorian and Friends Die in Fatal Crash after Using Marijuana: An 18 year old , was driving his truck emba and 19, died in the crash. According to the toxicology report, all three deceased at higher than 5 nanograms or more of active THC (delta-9 tetrahydrocannabinol) per 5 milliliter of blood, which under Colorado law is cons SECTION 2: Youth Marijuana Use Page | 29 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Man Killed, Woman and Two Children Injured after Vehicle Careens off I-76: to pass a semi- State Patrol, just before 7 a.m. trol, blew thought a guardrail, went airborne and flipped the truck nearly 20 feet down onto seatbelts and were ejected from the vehicle. Griego died at the scene. The female passenger suffered a shattered pelvis, broke her spine in three places, and was in a coma. The two children passengers, 7 year-old Jazlynn, had a punctured lung and, 6 year-old Alexis, had a fractured skull and broken collar bone. An autopsy of Griego showed he had 19ng/mL of THC in his system at the time of the crash. That is nearly 4 6, 7 times the legal limit. Boulder Teen Pleads Guilty to Vehicular Homicide: Quinn Hefferan faces up to two years in the Colorado Department of Youth Corrections for killing Stacy th Reynolds (30) and Joe Ramas (39) on May 7 2016. Hefferan, who was 17 years old at asleep at the wheel while trying to make his midnight curfew. Hefferan rear ended the times the legal limit of THC in his system. Cassie Drew, a friend of the couple says, changed and we recognize that, we recognize how much this will impact him and his 8, 9 Middle School Counselor Killed by High Driver as She Helped Fellow Motorist: On July 10, 2016, a counselor at Wolf Point Middle School, in Montana, was hit by a car and killed by an impaired driver in Colorado as she stopped to help another driver. The Jefferson County coroner in Colorado identified the woman as Jana Elliott, 56. She died of multiple blunt force trauma injuries. Elliott is identified as a counselor for the sixth grade in Montana. The driver who hit Elliott, identified as Curtis Blodgett, 24, is being charged with vehicular homicide for allegedly smoking marijuana prior to the crash, according to The Denver Post. Blodgett allegedly admitted he had smoked marijuana that day. Detectives are working to determine whether Blodgett was legally impaired at the time of How much he had in his system and what he had in his system will determine whether additiona Lakewood Police Spokesman Steve Davis told The Post (subsequent testing revealed Blodgett had 4.8 ng/mL of THC in his system). SECTION 2: Youth Marijuana Use Page | 30 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 According to the Lakewood Police Department Traffic Unit, Elliott was driving on US Highway 6 when a vehicle traveling in the left lane lost the bicycle it was carrying on its top. The driver of the vehicle stopped to retrieve the bike and Elliott stopped along the shoulder as well to help. After they retrieved the bicycle and were preparing Elliott 10 was killed in the crash. Suspected DUI Driver Runs A Red Light: On August 30th, 2017, at around 5:30 a.m. a driver in a Toyota 4Runner ran a red light and crashed into a public transit bus. Two 4Runner and the crash is being investigated as a possible DUI for alcohol and 11 for several hours during rush hour. For Further Information on Impaired Driving See Page 147 Sources 1 th The Denver Post, August 25, 2017, <http://www.denverpost.com/2017/08/25/colorado-marijuana-traffic-fatalities/>, th accessed August 25, 2017. 2 Washington, DC, revised May 2015, <https://crashstats.nhtsa.dot.gov/Api/Public/ViewPublication/812013>, accessed August st 31, 2017. 3 Cost of a DUI brochure, <https://www.codot.gov/library/brochures/COSTDUI09.pdf/view>, accessed February 19, 2015. SECTION 2: Youth Marijuana Use Page | 31 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 4 Amelia Arvesen, Times-Call, July <http://www.timescall.com/news/crime/ci_30185142/driver-accused-killing-longmont- girl-bike-thought- accessed July 29, 2016. 5 th Xanax and marijuana in their system,The Denver Post, July 7 2016, <http://www.denverpost.com/2016/07/07/teens-conifer-crash-traces-drugs-thc/>, th accessed August 28, 2017. 6 Allison Sylte careens off I-9NEWS, December 27, 2016, <http://www.9news.com/traffic/man- killed-woman-and-two-children-injured-after-vehicle-careens-off-i-76/379100251>, accessed September 25, 2017. 7 Macradee Aegerterof I-76 may FOX31 Denver, December 28, 2016, <http://kdvr.com/2016/12/28/csp- marijuana-may-have-been-contributing-factor-in-deadly-crash/>, accessed September 25, 2017. 8 vehicular homicide, th DUI in crash that killed 2,The Daily Camera, December 16, 2016, <http://www.dailycamera.com/news/boulder/ci_30665690/quinn-hefferan-boulder-fatal- crash-dui>, accessed August 23, 2017. 9 rash That Killed Boulder th Couple,CBS Denver, June 11 2016, <http://Denver.cbslocal.com/2016/06/11/stacey- rd reynolds-joe-rama-fatal-crash/>, accessed August 23, 2017. 10 Aja KTVS.com, July 13, 2016, <http://www.ktvq.com/story/32440083/wolf-point-school-counselor-killed-by-car-while- helping-other-driver-in-colorado>, accessed July 13, 2016. 11 hed th into RTD bus in Wheat Ridge,Fox 31 Denver, August 30 2017, <http://kdvr.com/2017/08/30/rtd-bus-3-vehicles-involved-in-wheat-ridge-crash/>, th accessed August 30, 2017. SECTION 2: Youth Marijuana Use Page | 32 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 SECTION 2: Youth Marijuana Use Some Findings Youth past month marijuana use increased 12 percent in the three-year average (2013-2015) since Colorado legalized recreational marijuana compared to the three-year average prior to legalization (2010-2012). The latest 2014/2015 results show Colorado youth ranked #1 in the nation for past month marijuana use, up from #4 in 2011/2012 and #14 in 2005/2006. Colorado youth past month marijuana use for 2014/2015 was 55 percent higher than the national average compared to 39 percent higher in 2011/2012. The top ten states with the highest rate of current marijuana youth use were all medical marijuana states, whereas the bottom ten were all non-medical- marijuana states. Surveys NOT Utilized Rocky Mountain HIDTA did not use the following datasets in this report because of the following reasons: Healthy Kids Colorado Survey (HKCS) The HKCS shows a 7.6 percent increase in student marijuana use from 2013 (19.7 percent) to 2015 (21.2 percent). According to a front page article in The Denver Post (June 21, 2016), the increase The Denver Post released an editorial on June 22, 2016 titled picture of student marijuana use in Colorado. SECTION 2: Youth Marijuana Use Page | 33 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Some concerns with the HKCS include: ndrd Jefferson County (the 2 largest school district), Douglas County (the 3 largest nd school district), El Paso County (Colorado Springs, 2 largest metro area), and Weld County results were listed as N/A which means data not available due to low participation in the region. NOTE: This is a similar reason why HKCS results were considered unweighted by the national YRBS survey. In 2015 the HKCS survey had a response rate of 46 percent, which is well below the 60 percent rate required by YRBS. Even though HKCS samples a large number of students, their participation rate is below the industry standard for weighted data. From 2013 to 2015, marijuana use: o High School increased 14 percent among seniors and 19 percent among juniors. th o Middle School increased 96 percent for 7 Graders and 144 percent th among 6 Graders. Healthy Kids Colorado Survey: Current Marijuana Use for High School and Middle School Students in Colorado 20132015 27.8 30.0 26.3 24.3 22.1 25.0 18.8 19.0 20.0 13.7 12.4 15.0 8.88.8 8.7 10.0 4.5 2.2 5.0 0.9 0.0 6th7th8th9th10th11th12th SOURCE: Colorado Department Public Health and Environment, Healthy Kids Colorado Survey For a detailed analysis and additional data, go to www.rmhidta.org and click on the Down Flat? Examine the SECTION 2: Youth Marijuana Use Page | 34 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Monitoring the Future (MTF) Study Although Colorado cited Monitoring the Future data in a response letter to Attorney General Jeff Sessions, the study is designed to be nationally-representative and not state-representative. MTF does not provide usable estimates for the specific state of Colorado total U.S. population; thus, the sampling would only be 1.6 percent of Colorado schools (400) or about 6 schools per year. Since 2010, the survey sampled an average of 4.6 Colorado schools. In 2014 and 2015, there were four schools surveyed each year of which three were eighth grade. Therefore, the MTF study is not useful for state data pertaining to Colorado for school-age drug use data and trends. Centers for Disease Control Youth Risk Behavior Survey (YRBS) In 2015, Colorado fell short of the required 60 percent participation rate and was, therefore, not included with weighted data in this survey. Additionally, upon further review, it was discovered that since 1991 the state of Colorado has only been represented in the High School YRBS survey with weighted data four times. Since 1995, Colorado has only been represented in the Middle School YRBS survey by weighted data twice. States that participated in the 2015 Middle School and High School YRBS surveys are represented in dark purple in the below maps. It should be noted, in 2015, high schools in the following ten states were not included with weighted high school data: Utah, Colorado, Kansas, Texas, Louisiana, Georgia, Iowa, Wisconsin, Ohio, and New Jersey. Washington, Oregon, and Minnesota did not participate in the survey. Centers for Disease Control Youth Risk Behavior Survey 2015 YRBS Participation Map Middle Schools High Schools SOURCE: Centers for Disease Control and Prevention, Adolescent and School Health, YRBS Participation Maps and History http://www.cdc.gov/healthyyouth/data/yrbs/participation.htm SECTION 2: Youth Marijuana Use Page | 35 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Use Data Youth Ages 12 to 17 Years Old Average Past Month Use of Marijuana Youth Ages 12 to 17 Years Old 11.85% 10.60% 12.00% 10.00% 8.00% 6.00% 4.00% 2.00% 12% Increase 0.00% 2010-20122013-2015 Pre-Recreational LegalizationPost-Recreational Legalization SOURCE: SAMHSA.gov, National Survey on Drug Use and Health 2014 and 2015 Past Month Marijuana Use Youth Ages 12 to 17 Years Old National AverageColorado Average Legalization 16.00 Commercialization 14.00 12.56 11.16 11.13 10.72 12.00 10.47 10.17 9.91 9.13 10.00 8.15 7.60 8.00 7.64 6.00 7.55 7.38 7.22 7.20 7.15 7.03 6.74 6.676.67 4.00 2.00 0.00 05/0606/0707/0808/0909/1010/1111/1212/1313/1414/15 Annual Averages of Data Collection SOURCE: SAMHSA.gov, National Survey on Drug Use and Health 2014 and 2015 SECTION 2: Youth Marijuana Use Page | 36 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Prevalence of Past 30-Day Marijuana Use Youth Ages 12 to 17 Years Old 2006-20082008-20102010-20122012-2014 14.00% 12.00% 10.00% 8.00% 6.00% 4.00% 2.00% 0.00% United StatesColoradoDenver Metro SOURCE: SAMHSA.gov, National Survey on Drug Use and Health, Substate Region Estimates 2006-2014 NOTE: S UB-STATE DATA IS ONLY AVAILABLE FROM THE N ATIONAL S URVEY ON D RUG U SE AND H EALTH IN THE ABOVE TIMEFRAMES. SECTION 2: Youth Marijuana Use Page | 37 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Past Month Usage, 12 to 17 Years Old, 2014/2015 Colorado Vermont Alaska Rhode Island *Maine New Hampshire Oregon *Massachusetts Maryland Washington Montana New Mexico Connecticut *California Indiana Michigan Arizona Wisconsin New York Delaware *Nevada **Pennsylvania Georgia Texas New Jersey **Florida Wyoming South Carolina Missouri Illinois Idaho **Arkansas Kansas South Dakota Kentucky Minnesota **North Dakota Hawaii West Virginia **Ohio North Carolina Tennessee Virginia Oklahoma As of 2015: **Louisiana Legalized Recreational/Medical Marijuana Iowa Legalized Medical Marijuana Mississippi Non-LegalizedMedical Marijuana Nebraska Alabama Utah 0.00%2.00%4.00%6.00%8.00%10.00%12.00% SOURCE: SAMHSA.gov, National Survey on Drug Use and Health 2014 and 2015 NOTE: *California, Massachusetts, Maine and Nevada voted to legalize recreational marijuana in November 2016 **States that had legislation for medical marijuana signed into effect during 2015 SECTION 2: Youth Marijuana Use Page | 38 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Average Past Month Use Youth Ages 12 to 17 Years Old, 2014/2015 10.09% 12.0% 8.25% 10.0% 6.19% 8.0% 6.0% 4.0% 2.0% 0.0% Non-Medical MarijuanaMedical Marijuana StatesRecreational/Medical StatesMarijuana States SOURCE: SAMHSA.gov, National Survey on Drug Use and Health 2014 and 2015 Past Month Marijuana Use Youth Ages 12 to 17 Years Old, 2014/2015 Top 10 Bottom 10 (Medical/Recreational States) (Non-Medical or Recreational States) National Average = 7.20% 1. Colorado 11.13% 41. North Carolina 5.97% 2. Vermont 10.86% 42. Tennessee 5.90 % 3. Alaska 10.64% 43. Virginia 5.44% 4. Rhode Island 10.19% 44. Oklahoma 5.42% 5. Maine 10.01% 45. Louisiana 5.33% 6. New Hampshire 9.44% 46. Iowa 5.30% 7. Oregon 9.42% 47. Mississippi 5.29% 8. Massachusetts 9.22% 48. Nebraska 5.26% 9. Maryland 9.20% 49. Alabama 5.16% 10. Washington 9.17% 50. Utah 4.54% SOURCE: SAMHSA.gov, National Survey on Drug Use and Health 201 4 and 201 5 SECTION 2: Youth Marijuana Use Page | 39 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Colorado Probation Percent of All Urinalysis Tests Positive for Marijuana Youth Ages 10 -17 Years Old Legalization Commercialization 45.00 40.00 34.83 34.40 33.77 31.91 35.00 28.37 28.31 26.59 30.00 26.15 25.26 24.90 22.24 25.00 20.00 15.00 10.00 5.00 0.00 20062007200820092010201120122013201420152016 SOURCE: Division of Probation Services/State Court SECTION 2: Youth Marijuana Use Page | 40 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 School Data Impact on School Violation Numbers -046 and House Bill 12- Colorado Department of Public Safety, Marijuana Legalization in Colorado: Early Findings, A Report Pursuant to Senate Bill 13-283, March 2016 Data for the 2016-2017 school year were not available by the time of release for this report. SOURCE: Colorado Department of Education, 10-Year Trend Data: State Suspension and Expulsion Incident Rates and Reasons NOTE: T HE C OLORADO D EPARTMENT OF E DUCATION BEGAN COLLECTING MARIJUANA VIOLATIONS SEPARATELY FROM ALL DRUG VIOLATIONS DURING THE 2015-2016 SCHOOL YEAR. SECTION 2: Youth Marijuana Use Page | 41 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 SOURCE: Colorado Department of Education, 10-Year Trend Data: State Suspension and Expulsion Incident Rates and Reasons In school year 2015/2016, 62 percent of all drug expulsions and suspensions were for marijuana violations. SOURCE: Colorado Department of Education, 10-Year Trend Data: State Suspension and Expulsion Incident Rates and Reasons In school year 2015/2016, 73 percent of all drug related referrals to law enforcement were for marijuana violations. SECTION 2: Youth Marijuana Use Page | 42 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Number of Reported School Dropouts 11,114 11,200 11,000 10,664 10,800 10,546 10,530 10,600 10,400 10,200 2012-20132013-20142014-20152015-2016 SOURCE: Colorado Department of Education NOTE: R OCKY M OUNTAIN HIDTA HAS BEEN ASKED ABOUT THE NUMBER OF SCHOOL DROPOUTS IN C OLORADO NUMEROUS TIMES AND IS, THEREFORE, PROVIDING THE DATA. R OCKY M OUNTAIN HIDTA IS NOT ATTRIBUTING THE NUMBER OF DROPOUTS TO MARIJUANA LEGALIZATION. Colorado School Resource Officer Survey In June 2017, 76 school resource officers (SRO) participated in a survey concerning marijuana in schools. The majority were assigned to high schools and had a tenure of three years or more as a SRO. They were asked for their professional opinion on a number of questions. The questions and their responses are shown in the following pages. SECTION 2: Youth Marijuana Use Page | 43 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Question: Since the legalization of recreational marijuana, what impact has there been on marijuana-related incidents at your school? Impacton Marijuana-Related Incidents, 2017 10% Increase 4% Decrease No Change 86% SOURCE: Colorado Association of School Resource Officers (CASRO) and Rocky Mountain HIDTA Question: What were the most predominant marijuana violations by students on campus? Predominant Marijuana Violations, 2017 44% 50% 36% 45% 40% 35% 30% 25% 20% 15% 6% 5% 10% 2% 5% 0% Student sharingStudent sellingStudent inStudent inStudent under marijuana withmarijuana topossession ofpossession ofthe influence other studentsother studentsmarijuanamarijuanaduring school infused edibleshours SOURCE: Colorado Association of School Resource Officers (CASRO) and Rocky Mountain HIDTA SECTION 2: Youth Marijuana Use Page | 44 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Question: Where do the students get their marijuana? Student Marijuana Source, 2017 45% 39% 40% 35% 26% 23% 30% 25% 20% 15% 7% 5% 10% 2% 5% 0% MedicalMedicalMedicalParentsBlack MarketFriend Who MarijuanaMarijuanaMarijuanaObtained it CardholdersDispensariesCaregiversLegally SOURCE: Colorado Association of School Resource Officers (CASRO) and Rocky Mountain HIDTA School Counselor Survey Since the 2015 survey, the Colorado School Counselor Association has elected not to participate in any further surveys. In August 2015, 188 school counselors participated in a survey concerning the legalization of marijuana in schools. The majority were assigned to high schools with an average tenure of ten years. They were asked for their professional opinion on a number of question. The questions and their responses are shown in the following pages. SECTION 2: Youth Marijuana Use Page | 45 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Question: Since the legalization of recreational marijuana, what impact has there been on marijuana-related incidents at your school? Impacton Marijuana-Related Incidents, 2015 Increased 30% Decreased 2% 68% No Change SOURCE Colorado School Counselor Association (CSCA) and Rocky Mountain HIDTA Question: What were the most predominant marijuana violations by students on campus? Predominant Marijuana Violations, 2015 51% 60% 50% 30% 40% 30% 9% 20% 6% 5% 10% 0% Student sellingStudent sharingStudent inStudent inStudent under marijuana tomarijuana withpossession ofpossession ofthe influence other studentsother studentsmarijuanamarijuanaduring school infused edibleshours SOURCE Colorado School Counselor Association (CSCA) and Rocky Mountain HIDTA SECTION 2: Youth Marijuana Use Page | 46 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Question: Where do the students get their marijuana? Student Marijuana Source, 2015 SOURCE Colorado School Counselor Association (CSCA) and Rocky Mountain HIDTA Case Examples My son and his Marijuana: It was February 6th at 3:15 a.m. when my oldest son woke me and urgently whispered that his brother had just tried to take his own life. I -born, a high achieving, gifted young man had just attempted suicide by hanging. Thankfully, his brother discovered him and saved his life before we lost him. It changed our family forever. Later that morning after the assessment and intake procedure, the hospital social with his heavy marijuana use had caused a psychotic break called marijuana induced psychosis. She said this was quite common among young people today. I felt blindsided as I had no idea my son was using marijuana. Sadly, in-patient treatment was not successful, nor was out-patient treatment. -ending appointments, meetings, confrontations, stress, and bizarre drama that we never SECTION 2: Youth Marijuana Use Page | 47 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 imagined we would experience. It was both frustrating and heartbreaking to listen as my son frequently described his passionate commitment to marijuana and observe his inability to see how negatively it impacted even controlled him. We learned we were not fighting a behavior but a mind-set that was cemented into his belief system. Marijuana had become his life, his religion, and his identity. In spite of a multitude of problems and ongoing depression that continue to prevent him from living successfully, his belief that marijuana will solve all of his troubles remains 1 ingrained in him and leaves our family feeling fearful and often hopeless to help him. Teen Shot While Trying to Sell Marijuana: While attempting to sell marijuana to a car filled with four other teenagers, an 18 year old in Greeley, Colorado was shot with a handgun. The seller had been leaning into the car window when the occupants shot him and quickly drove away. The wound sustained by the teenager was not life 2 threatening. One Teen Wounded, Another Killed While Trying to Steal Marijuana: Shortly after 2 th a.m. on Sunday, October 9, 2016, Denver Police received a call from a 14-year-old boy stating that he and his friend had been shot. Both boys had been trying to steal marijuana plants from a backyard when the resident was alerted to their presence and fired multiple shots at the boys. Both boys were struck as they were trying to escape the backyard, the 14-year-old was wounded and the 15-year old boy was killed. The home owner was arrested and held for investigation of murder, attempted murder and 3 investigation of felony marijuana cultivation. SECTION 2: Youth Marijuana Use Page | 48 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Some Comments from School Resource Officers They End Up Sick: o -prom after eating some marijuana edibles. She later got very sick and was transported by ambulance to the hospital. She o edibles, later that week, and then the other student shared the edibles with 5 other people, who became sick. All students were disciplined. It is very common for students to bring edibles and share with others, and they end o and then overdosed on them and ende Organized and Well-planned Distribution: o o different relatives, who purchased the recreational MJ legally, then sold it to other students. The 12 year old suspect had also recruited other students to sell the MJ. The crime was eventually reported by the sister of on o (father wanted to start a grow operation) frequently peddled marijuana on and around campus. Eventually, school/police alerted that he was o dent has a medicinal marijuana card, became marijuana dealer to o -12 grades). Students were charged \[with distribution\] of marijuana, it was organized and well-planned in school distribution (9-11 grades). Burglarized Dispensary: overabundance of dabs and shatter that was still in the packaging from a dispensary that had been burglarized the previous weekend by five masked individuals that were SECTION 2: Youth Marijuana Use Page | 49 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Student Commits Suicide: campus. He was distributing for another student. That student was obtaining high quality marijuana on the black market. Original was charged and committed suicide 3 Fine for Their Kids to Use: middle school obtain marijuana and use marijuana with their families who all seem to have their own marijuana grows. Mosmedicine is fine for their kids to Social Media Delivery Service: hash/marijuana/shatter and have it delivered to their local park or fast food joint. No names exchanged and very difficult to prove a case. Was able to get a warrant on a Attempting to Official a Game: Leave Campus and Come Back High: and come back after lunch. Adult dealers have trolled \[the\] parking lot for students looking to buy marijuana. Lots of marijuana use at juvenile parties high school level where students leave campus, get high and come back to school. Some are caught with possession of marijuana and some are only Young Students Stealing from Parents: th grader stealing and then bringin th grader stealing recreational marijuana from parents and bringing it to SECTION 2: Youth Marijuana Use Page | 50 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Some Comments from School Counselors Halls Reek of Pot After Lunch: reek of pot, so many kids are high that it is impossible to apprehend all but the pus and smoke during lunch with friends. They will run home iors but thth on occasion, seniors will provide marijuana to 9 or 10 -campus that they were high. Student was escorted to the office, student admitted they were indeed high to the -3 students smoked marijuana about a block away from school. They smelled like pot when they got Just a Plant: fifth grade boy offered marijuana to another fifth grader on the playground. In October of 2014 a kindergarten girl described the pipe in grade girl reported that her Arrives at School Stoned: students who either come to school high, or have it on hing a lesson in class during first period that started 7:30 AM and 2 SECTION 2: Youth Marijuana Use Page | 51 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 school counselor and the RSO (sic). He was assessed as being high and admitted confronted he told the teacher that he smoked it at home the night before but denied being high at the time. Later, he confirmed that he had smoked early that New Use of Bathrooms: thth grade male student had marijuana in his locker, classmates reported it. 8 grade female student smoked a joint in a school bathroom during school hours. th and told several friends who began getting bathroom break passes from various classrooms. Security noted an increased traffic flow to and from that restroom to school under the influence after meeting at homes where parents were absent, sharing marijuana thth off campus and then bringing it on campus. 7 and 8 grade students have been with at least 5 students last year alone that have been showing significant signs of drug use or were caught and they all said they will not stop using weed not a Grades Decline: gone up. We have a savvy population that knows to keep it away from school. However, I have seen a huge spike in talking with kids about it in my sessions. Last year I had two very intelligent students (above 4.0) that used marijuana 2-6 times a week. Both of them had grades decline and significant social emotional issues spike in the spring Dad Allows Pot Smoking: high at school. Our officer assessed both of them and discovered that their father, who He thought it would make the SECTION 2: Youth Marijuana Use Page | 52 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Parents High: parents showing up to school high. Kids have also brought \[marijuana\] to school to Difficulty in Assessment: l, it is more difficult to evaluate what substance a student is under the influence of. We can smell alcohol and smoked Drug Canine Use: for more use of drug dogs and not having to forewarn students or parents when these dogs will be present. Students and especially dealers, the ones we need to catch, are very vigilant For Further Information on Youth Marijuana Use See Page 151 Sources 1 Jo McGuire Inc., August thth 29, 2017, < https://jomcguire.wordpress.com/>, accessed August 29, 2017. 2 Nate Miller, The Tribune, May 16, 2017, <http://www.greeleytribune.com/news/crime/sheriffs-office-seeks-publics-help-to-learn- more-about-northeast-greeley-shooting/>, accessed September 12, 2017. 3 Kirk Mitchell, marijuana-Denver Post, October 10, 2016, <http://www.denverpost.com/2016/10/10/marijuana-grow-house-slaying-denver-man- arrested/>, accessed September 12, 2017. SECTION 2: Youth Marijuana Use Page | 53 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 THIS PAGE INTENTIONALLY LEFT BLANK SECTION 2: Youth Marijuana Use Page | 54 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 SECTION 3: Adult Marijuana Use Some Findings College age past month marijuana use increased 16 percent in the three-year average (2013-2015) since Colorado legalized recreational marijuana compared to the three-year average prior to legalization (2010-2012). The latest 2014/2015 results show Colorado college-age adults ranked #2 in the nation for past-month marijuana use, up from #3 in 2011/2012 and #8 in 2005/2006. Colorado college age past month marijuana use for 2014/2015 was 61 percent higher than the national average compared to 42 percent higher in 2011/2012. Adult past-month marijuana use increased 71 percent in the three-year average (2013-2015) since Colorado legalized recreational marijuana compared to the three-year average prior to legalization (2010-2012). The latest 2014/2015 results show Colorado adults ranked #1 in the nation for past month marijuana use, up from #7 in 2011/2012 and #8 in 2005/2006. Colorado adult past month marijuana use for 2014/2015 was 124 percent higher than the national average compared to 51 percent higher in 2011/2012. SECTION 3: Adult Marijuana Use Page | 55 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Use Data College Age 18 to 25 Years Old Average Past Month Use of Marijuana College Age 18 to 25 Years Old 31.50% 27.04% 40.00% 30.00% 20.00% 10.00% 16% Increase 0.00% 2010-20122013-2015 Pre-Recreational LegalizationPost-Recreational Legalization SOURCE: SAMHSA.gov, National Survey on Drug Use and Health 2014 and 2015 Past Month Marijuana Use College Age 18 to 25 Years Old National AverageColorado Average Legalization 50 Commercialization 45 40 31.75 31.24 35 29.05 27.26 26.81 26.35 30 24.28 23.44 22.21 21.43 25 20 15 19.7 19.32 18.8918.91 18.78 18.39 17.42 16.4216.45 16.34 10 5 0 05/0606/0707/0808/0909/1010/1111/1212/1313/1414/15 Annual Averages of Data Collection SOURCE: SAMHSA.gov, National Survey on Drug Use and Health 2014 and 2015 SECTION 3: Adult Marijuana Use Page | 56 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Prevalence of Past 30-Day Marijuana Use College Age 18 to 25 Years Old 2006-20082008-20102010-20122012-2014 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% United StatesColoradoDenver Metro SOURCE: SAMHSA.gov, National Survey on Drug Use and Health, Substate Region Estimates 2006-2014 NOTE: S UB-STATE DATA IS ONLY AVAILABLE FROM THE N ATIONAL S URVEY ON D RUG U SE AND H EALTH IN THE ABOVE TIMEFRAMES. SECTION 3: Adult Marijuana Use Page | 57 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Past MonthUsage, 18 to 25 Years Old, 2014/2015 Vermont Colorado *Maine New Hampshire Rhode Island *Massachusetts Oregon Alaska Connecticut Maryland Montana Michigan New York Washington Delaware South Carolina **Florida Indiana New Mexico *California Illinois **Ohio Missouri Minnesota North Carolina **Pennsylvania New Jersey Arizona West Virginia Georgia Virginia Wisconsin *Nevada South Dakota **Arkansas Nebraska Kentucky **Louisiana Hawaii Tennessee Kansas Wyoming Texas As of 2015: Oklahoma Legalized Recreational/Medical Marijuana **North Dakota Legalized Medical Marijuana Alabama Non-Legalized Medical Marijuana Mississippi Idaho Iowa Utah 0.00%5.00%10.00%15.00%20.00%25.00%30.00%35.00%40.00% SOURCE: SAMHSA.gov, National Survey on Drug Use and Health 2013 and 2014 NOTE: *California, Massachusetts, Maine and Nevada voted to legalize recreational marijuana in November 2016 **States that had legislation for medical marijuana signed into effect during 2015 SECTION 3: Adult Marijuana Use Page | 58 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Average Past Month Use College Age 18 to 25 Years Old, 2014/2015 26.23% 23.19% 30.00% 25.00% 16.81% 20.00% 15.00% 10.00% 5.00% 0.00% Non-MedicalMedical MarijuanaRecreational/Medical Marijuana StatesStatesMarijuana States SOURCE: SAMHSA.gov, National Survey on Drug Use and Health 2014 and 2015 Past Month Marijuana Use College Age 18 to 25 Years Old, 2014/2015 Top 10 Bottom 10 (Medical/Recreational States) (Non-Medical or Recreational States) National Average = 19.99% 1. Vermont 34.95% 41. Kansas 15.73% 2. Colorado 31.75% 42. Wyoming 15.64% 3. Maine 29.72% 43. Texas 15.08% 4. New Hampshire 29.12% 44. Oklahoma 14.87 % 5. Rhode Island 28.89% 45. North Dakota 14.77% 6. Massachusetts 27.39% 46. Alabama 14.33% 7. Oregon 26.29% 47. Mississippi 13.91% 8. Alaska 25.02% 48. Idaho 13.69% 9. Connecticut 24.99% 49. Iowa 12.67% 10. Maryland 24.87% 50. Utah 11.07% SOURCE: SAMHSA.gov, National Survey on Drug Use and Health 2014 and 2015 SECTION 3: Adult Marijuana Use Page | 59 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Adults Age 26+ Years Old Average Past Month Use of Marijuana Adults Ages 26+ Years Old 13.55% 14.00% 12.00% 7.91% 10.00% 8.00% 6.00% 4.00% 2.00% 71% Increase 0.00% 2010-20122013-2015 Pre-Recreational LegalizationPost-Recreational Legalization SOURCE: SAMHSA.gov, National Survey on Drug Use and Health 2014 and 2015 Past Month Marijuana Use Adults Age 26+ Years Old National AverageColorado Average 20.00 Legalization 18.00 Commercialization 14.65 16.00 12.45 14.00 12.00 10.13 8.86 8.19 10.00 7.63 7.31 6.88 8.00 5.88 5.32 6.00 6.55 6.11 4.00 5.45 5.05 4.8 4.68 4.42 4.1 4.06 4.02 2.00 0.00 05/0606/0707/0808/0909/1010/1111/1212/1313/1414/15 Annual Averages of Data Collection SOURCE: SAMHSA.gov, National Survey on Drug Use and Health 2014 and 2015 SECTION 3: Adult Marijuana Use Page | 60 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Prevalence of Past 30-Day Marijuana Use Adults Age 26+ Years Old 2006-20082008-20102010-20122012-2014 14.00% 12.00% 10.00% 8.00% 6.00% 4.00% 2.00% 0.00% United StatesColoradoDenver Metro SOURCE: SAMHSA.gov, National Survey on Drug Use and Health, Substate Region Estimates 2006-2014 NOTE: S UB-STATE DATA IS ONLY AVAILABLE FROM THE N ATIONAL S URVEY ON D RUG U SE AND H EALTH IN THE ABOVE TIMEFRAMES. SECTION 3: Adult Marijuana Use Page | 61 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Past Month Usage, 26+ Years Old, 2014/2015 Colorado Alaska *Maine Vermont Oregon Rhode Island Washington New Hampshire Montana *Massachusetts New Mexico Michigan *California New York Connecticut Maryland Hawaii Arizona Indiana *Nevada Missouri South Carolina Illinois **Pennsylvania Delaware **Florida Georgia **Ohio Minnesota Kansas **Arkansas Kentucky North Carolina New Jersey South Dakota West Virginia Idaho Wisconsin Virginia Oklahoma Tennessee **Louisiana Wyoming As of 2015: Nebraska Legalized Recreational/Medical Marijuana Texas Legalized Medical Marijuana **North Dakota Non-Legalized Medical Marijuana Alabama Mississippi Utah Iowa 0.00%2.00%4.00%6.00%8.00%10.00%12.00%14.00%16.00% SOURCE: SAMHSA.gov, National Survey on Drug Use and Health 2014 and 2015 NOTE: *California, Massachusetts, Maine and Nevada voted to legalize recreational marijuana in November 2016 **States that had legislation for medical marijuana signed into effect during 2015 SECTION 3: Adult Marijuana Use Page | 62 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Average Past Month Use Adults Ages 26+ Years Old, 2014/2015 12.05% 14.00% 12.00% 8.01% 10.00% 8.00% 5.10% 6.00% 4.00% 2.00% 0.00% Non-Medical MarijuanaMedical Marijuana StatesRecreational/Medical StatesMarijuana States SOURCE: SAMHSA.gov, National Survey on Drug Use and Health 2014 and 2015 Past Month Marijuana Use Adults Ages 26+ Years Old, 2014/2015 Top 10 Bottom 10 (Medical/Recreational States) (Non-Medical or Recreational States) National Average = 6.76% 1. Colorado 14.65% 41. Tennessee 4.81% 2. Alaska 12.83% 42. Louisiana 4.71% 3. Maine 11.84% 43. Wyoming 4.71% 4. Vermont 11.61% 44. Nebraska 4.53% 5. Oregon 10.99% 45. Texas 4.32% 6. Rhode Island 10.39% 46. North Dakota 3.93% 7. Washington 9.74% 47. Alabama 3.86% 8. New Hampshire 9.65% 48. Mississippi 3.81% 9. Montana 9.41% 49. Utah 3.75% 10. Massachusetts 9.21% 50. Iowa 3.30% SOURCE: SAMHSA.gov, National Survey on Drug Use and Health 2014 and 2015 SECTION 3: Adult Marijuana Use Page | 63 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 1 Colorado Adult Marijuana Use Demographics According to the Colorado Behavior Risk Factor Surveillance System, 2016: 13.6 percent of adults (18+ years old) are current users of marijuana o Nearly half of current users (47 percent) report using marijuana daily 1 out of 5 current users (20 percent) report driving after using marijuana Top demographics of those who report current marijuana use: o Between 18 to 25 years old Next highest are those 26 to 34 years old o Black, Non- Hispanic individuals Next highest are Multiracial (Non-Hispanic) individuals o Gay/Lesbian/Bisexual adults o Males The Southwest region of Colorado reports the highest current marijuana use o The Southeast and Northwest regions are tied for second highest NOTE: T HE B EHAVIORAL R ISK F ACTOR S URVEILLANCE S YSTEM (BRFSS) COLLECTS DATA ON ADULT, INDIVIDUAL-LEVEL BEHAVIORAL HEALTH RISK FACTORS. Q UESTIONS SPECIFICALLY REGARDING MARIJUANA USE WERE NOT ADDED UNTIL 2014. M ONITORING H EALTH C ONCERNS R ELATED TO M ARIJUANA IN C OLORADO: 2016, C OLORADO D EPARTMENT OF P UBLIC H EALTH AND E NVIRONMENT Case Examples Young Professional Commits Suicide at 23, Parents Question if THC is to Blame: Marc Bullard, a young professional with no apparent signs of depression or mental illness committed suicide in April 2015, he was on top of the world explaining in a video documenting his success that, had been writing entries such as: I found out I was dabbing too much which I already knew and had cut back in February. But apparently if you overdo it, you can get almost like poison and experience some negative effects. SECTION 3: Adult Marijuana Use Page | 64 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 eard of dabbing. 2 Parents Charged with Child Abuse for Identical Deaths of Two Babies: In Aurora, Colorado a couple was booked into jail on two counts of misdemeanor child abuse. Charges were filed against the couple after their second child died under similar circumstances as their first child who died two years previously. According to police reports, death as shown on autopsy reports for each child was listed as undetermined, however per the Arapahoe County Coroner Dr. Kelly Lear- 3 Man Shoots Wife and Kills Neighbor in a Marijuana and Caffeine-Fueled Paranoid State: While home for lunch, Dr. Kenneth Atkinson heard shots being fired next door been shot in the back by her husband Kevin Lyons. Dr. Atkinson attempted to attend to head at point-blank range from sports, a car wreck and other activities that, combined with substance abuse and difficult circumstances in his life, including marital and financial problems, left him delusional. Lyons was also in a marijuana and caffeine-fueled paranoid state on the day 4 For Further Information on Adult Marijuana Use See Page 152 SECTION 3: Adult Marijuana Use Page | 65 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Sources 1 Colorado Behavioral Risk Factor Surveillance System 2016 2 9News, <http://www.9news.com/news/health/marijuana-in-colorado-a-warning-about- dabbing/346018775>, accessed September 12, 2017. 3 Rob Low Fox 31News, <http://kdvr.com/2017/03/07/parents- charged-with-child-abuse-for-identical-deaths-of-2-babies/>, accessed April 19, 2017. 4 Denver Post, <http://www.denverpost.com/2017/06/05/kevin-lyons-centennial-shooting-rampage- killed-kenneth-atkinson/>, accessed September 12, 2017. SECTION 3: Adult Marijuana Use Page | 66 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 SECTION 4: Emergency Department and Hospital Marijuana- Related Admissions Some Findings The yearly rate of emergency department visits related to marijuana increased 35 percent after the legalization of recreational marijuana (2011-2012 vs. 2013- September 2015). Number of hospitalizations related to marijuana: o 2011 6,305 o 2012 6,715 o 2013 8,272 o 2014 11,439 o Jan-Sept 2015 10,901 The yearly number of marijuana-related hospitalizations increased 72 percent after the legalization of recreational marijuana (2009-2012 vs. 2013-September 2015). SECTION 4: Emergency Department and Hospital Marijuana-Related Admissions Page | 67 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Definitions Marijuana-Related: Amarijuana mata could be obtained from lab tests, patient self-admission or some other form of validation obtained by the provider. Being marijuana-related does not necessarily prove marijuana was the cause of the emergency department admission or hospitalization. International Classification of Disease (ICD): A medical coding system used to classify diseases and related health problems. **In 2015, ICD-10 (the tenth modification) was implemented in place of ICD-9. Although ICD-10 will allow for better analysis of disease patterns and treatment outcomes for the advancement of medical care, comparison of trends before and after the conversion can be made difficult and/or impossible. The number of codes increased from approximately 13,600 codes to approximately 69,000 codes. For the above reasons, hospitalization and emergency department data is only provided pre-conversion to ICD- 1 10. Emergency Department Data Colorado Department of Public Health and Environment NOTE: "P OSSIBLE M ARIJUANA E XPOSURES, D IAGNOSES, OR B ILLING C ODES IN A NY OF L ISTED D IAGNOSIS C ODES: T HESE DATA WERE CHOSEN TO REPRESENT THE HD AND ED VISITS WHERE MARIJUANA COULD BE A CAUSAL, CONTRIBUTING, OR COEXISTING FACTOR NOTED BY THE PHYSICIAN DURING THE HD OR ED VISIT. F OR THESE DATA, MARIJUANA USE IS NOT NECESSARILY RELATED TO THE UNDERLYING REASON FOR THE HD OR ED VISIT. S OMETIMES THESE DATA ARE REFERRED TO AS HD OR ED VISITS WITH ANY MENTION OF MARIJUANA - C OLORADO D EPARTMENT OF P UBLIC H EALTH AND E NVIRONMENT, M ONITORING H EALTH C ONCERNS R ELATED TO M ARIJUANA IN C OLORADO: 2014 SECTION 4: Emergency Department and Hospital Marijuana-Related Admissions Page | 68 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Average Emergency Department Rates Related to Marijuana* 889 ** 1,000 660 800 600 400 200 35% Increase 0 (2013-Sept 2015**) (2011-2012)(2013-Sept 2015) Pre-Recreational LegalizationPost-Recreational Legalization *Rates of Emergency Department (ED) Visits with Possible Marijuana Exposures, Diagnoses, or Billing Codes per 100,000 ED Visits by Year in Colorado **Only 9 months of comparable 2015 data, see ICD definition on page 68 SOURCE: Colorado Department of Public Health and Environment NOTE: D ATA NOT AVAILABLE PRE-2011. EMERGENCY DEPARTMENT DATA FROM 2011 AND 2012 REFLECTS INCOMPLETE STATEWIDE REPORTING. I NFERENCES CONCERNING TRENDS, INCLUDING 2011 AND 2012, SHOULD NOT BE MADE. SECTION 4: Emergency Department and Hospital Marijuana-Related Admissions Page | 69 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Emergency Department Rates Related to Marijuana* 1,200 1,039 1,000 873 0 0 754 ** 0 , 701 800 0 0 618 1 r e 600 P Legalization s e t 400 a R 200 0 Jan -Sept 2015** 2011201220132014Jan - Sept 2015 *Rates of Emergency Department (ED) Visits with Possible Marijuana Exposures, Diagnoses, or Billing Codes per 100,000 ED Visits by Year in Colorado **Only 9 months of comparable 2015 data, see ICD definition on page 68 SOURCE: Colorado Department of Public Health and Environment, Monitoring Health Concerns Related to Marijuana in Colorado: 2016 NOTE: D ATA NOT AVAILABLE PRE-2011. EMERGENCY DEPARTMENT DATA FROM 2011 AND 2012 REFLECTS INCOMPLETE STATEWIDE REPORTING. I NFERENCES CONCERNING TRENDS, INCLUDING 2011 AND 2012, SHOULD NOT BE MADE. SECTION 4: Emergency Department and Hospital Marijuana-Related Admissions Page | 70 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Emergency Department Visits Related to Marijuana 18,255 20,000 14,148 15,000 10,476** 9,982 8,197 10,000 5,000 0 2011201220132014 Jan -Sept 2015** **Only 9 months of comparable 2015 data, see ICD definition on page 68 SOURCE: Colorado Hospital Association, Emergency Department Visit Dataset. Statistics prepared by the Health Statistics and Evaluation Branch, Colorado Department of Public Health and Environment NOTE: D ATA NOT AVAILABLE PRE-2011. EMERGENCY DEPARTMENT DATA FROM 2011 AND 2012 REFLECTS INCOMPLETE STATEWIDE REPORTING. I NFERENCES CONCERNING TRENDS, INCLUDING 2011 AND 2012, SHOULD NOT BE MADE. SECTION 4: Emergency Department and Hospital Marijuana-Related Admissions Page | 71 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Hospitalization Data Colorado Department of Public Health and Environment NOTE: "P OSSIBLE M ARIJUANA E XPOSURES, D IAGNOSES, OR B ILLING C ODES IN A NY OF L ISTED D IAGNOSIS C ODES: T HESE DATA WERE CHOSEN TO REPRESENT THE HD AND ED VISITS WHERE MARIJUANA COULD BE A CAUSAL, CONTRIBUTING, OR COEXISTING FACTOR NOTED BY THE PHYSICIAN DURING THE HD OR ED VISIT. F OR THESE DATA, MARIJUANA USE IS NOT NECESSARILY RELATED TO THE UNDERLYING REASON FOR THE HD OR ED VISIT. S OMETIMES THESE DATA ARE REFERRED TO AS HD OR ED VISITS WITH ANY MENTION OF MARIJUANA - C OLORADO D EPARTMENT OF P UBLIC H EALTH AND E NVIRONMENT, M ONITORING H EALTH C ONCERNS R ELATED TO M ARIJUANA IN C OLORADO: 2014 Average Hospitalization Rates Related to Marijuana* 2,416 ** 2,500 2,000 1,330 1,500 1,000 500 82% Increase 0 (2010-2012)(2013-Sept 2015) (2013-Sept 2015**) Pre-Recreational LegalizationPost-Recreational Legalization *Rates of Hospitalization (HD) Visits with Possible Marijuana Exposures, Diagnoses, or Billing Codes per 100,000 HD Visits by Year in Colorado **Only 9 months of comparable 2015 data, see ICD definition on page 68 SOURCE: Colorado Department of Public Health and Environment SECTION 4: Emergency Department and Hospital Marijuana-Related Admissions Page | 72 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Hospitalization Rates Related to Marijuana* 3,500 3,025** Legalization 3,000 2,443 2,500 0 0 0 , 1,779 2,000 0 0 1 1,417 r 1,313 e 1,260 1,500 P s 963 911 e t 818 810 1,000 a R 500 0 200620072008200920102011201220132014Jan - Jan - SeptSept 2015**2015 *Rates of Hospitalization (HD) Visits with Possible Marijuana Exposures, Diagnoses, or Billing Codes per 100,000 HD Visits by Year in Colorado **Only 9 months of comparable 2015 data, see ICD definition on page 68 SOURCE: Colorado Department of Public Health and Environment, Monitoring Health Concerns Related to Marijuana in Colorado: 2014 SECTION 4: Emergency Department and Hospital Marijuana-Related Admissions Page | 73 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Average Hospitalizations Related to Marijuana 10,204** 12,000 10,000 5,933 8,000 4,070 6,000 4,000 72% 2,000 46% Increase Increase 0 2006-20082009-20122013-2015** 2013-September Pre-Post-Legalization 2015** CommercializationCommercialization **Only9 months of comparable 2015 data, see ICD definition on page 68 SOURCE: Colorado Hospital Association, Hospital Discharge Dataset. Statistics prepared by the Health Statistics and Evaluation Branch, Colorado Department of Public Health and Environment Hospitalizations Related to Marijuana 12,000 10,000 8,000 6,000 4,000 2,000 0 **Only 9 monthsof comparable 2015 data, see ICD definion on page 68 SOURCE: Colorado Hospital Association, Hospital Discharge Dataset. Statistics prepared by the Health Statistics and Evaluation Branch, Colorado Department of Public Health and Environment SECTION 4: Emergency Department and Hospital Marijuana-Related Admissions Page | 74 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Additional Sources Colorado Children's Hospital, Marijuana Ingestion Among Children Under 9 Years Old 20 16 16 15 10 9 10 7 3 5 1 0 2009201020112012201320142015 SOURCE: George Sam Wang, MD, Marie-Claire Le Lait, MS, Sara J. Deakyne, MPH, Alvin C. Bronstein, MD, Lalit Bajaj, MD, MPH, Genie Roosevelt, MD, MPH, July 25, 2016 Cost Cost of Emergency Room: The U.S. Department of Health and Human Services 2 estimates the average cost of an emergency room visit in 2014 was $1,533.00. SECTION 4: Emergency Department and Hospital Marijuana-Related Admissions Page | 75 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Case Examples Elderly Male with Altered Mental Status: I had an elderly male come to the \[emergency department\] wialtered mental status or stroke. The patient was essentially catatonic (awake but not responsive and not following commands). He had a very expensive stroke work up (including an EKG, CT, labs, etc.). Work up was negative and then family stated that he ate \[marijuana\] butter on his toast in the morning and then became catatonic. He had consumed at least 200 mg of THC. He was observed for many hours and improved. His \[emergency 3 department\] visit costs probably topped $10,000. Elderly Woman with Nausea and Vomiting: I had an elderly female who came to the \[emergency department\] with a chief complaint of significant nausea and vomiting. The patient had come to visit a family member who happened to work at a pot shop. They thought it would be f and gave her edibles. She ate too much and spent 12 hours in the emergency department vomiting 3 and screaming (probably some psychosis induced at the time). Marijuana Laced with Methamphetamine: I had a young woman who was in her last trimester of pregnancy, she came Her urine drug screen was positive for methamphetamines and \[marijuana\]. The patient states that the MJ (street) sellers, dip their products in cocaine or methamp She was using both and was pregnant. She justified the use of MJ for her anxiety and did 3 not want to hear about how the MJ would or could affect her child. High on Marijuana while Riding a Bicycle: A 16 \[year old\] male came after being struck by a car while riding a bike. He had been smoking marijuana. He was morbidly obese (over 300 pounds), not in school and getting his MJ from his parents who thought 3 legal. Unresponsive after an Edible Overdose: I just had a case last week of a young patient who ate a full bag of the chocolates, 100 mcg of THC per chocolate. She presented unresponsive, GCS of 6. (Only slightly withdrew to painful stimuli, otherwise unresponsive). She went to the ICU and there was just observed until she woke up. She stayed in the ED for over 8 hours with no change before going to the 4 ICU. There were no other substances on her drug screens that were positive. SECTION 4: Emergency Department and Hospital Marijuana-Related Admissions Page | 76 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Dangers of Marijuana Experienced Firsthand: A May 2017 article written by Dr. Brad Roberts described his experience of returning to his home town of Pueblo, CO in order to serve the community he grew up in. I recently finished my residency in emergency medicine and began to practice in Pueblo, Colorado. I grew up there, and I was excited to return home. However, when I returned home, the Pueblo I once knew had drastically changed. Where there were once hardware stores, animal feed shops, and homes along dotted farms, I now found marijuana shopsand lots of them. Among the various observations the newly minted doctor noted: Multiple different types of patients are coming into the emergency department with a variety of unexpected problems such as marijuana-induced psychosis, dependence, burn injuries, increased abuse of other drugs, increased homelessness and its associated problems, and self-medication with marijuana to treat their medical problems instead of seeking appropriate medical care. Dr. Roberts recalled a few specific incidents in which marijuana was directly o the emergency department. Among the specific incidents were cases in which a teenage girl had to be restrained after dabbing highly potent THC. Additionally, a and to hang himself three times). Lastly, two young men presented with severe burns due to a butane hash oil explosion they created when trying to make concentrated THC. The greatest concern that I have is the confusion between medical and recreational marijuana. Patients are being diagnosed and treated from the marijuana shops by those without any medical training. I have had patients bring in bottles with a recommended strain of cannabis and frequency of use for a stated medical problem given at the recommendation of a marijuana shop employee. My colleagues report similar encounters, with one reporting seeing two separate patients with significantly altered sensorium and with bottles labeled 60 percent THC. They were taking this with opioids and benzodiazepines. After discussing a variety of significantly adverse health effects of marijuana use, Dr. Roberts stated use. If we are going to use this as a medication, then we should use it as we use other medications. It should have to undergo the same scrutiny, Food and Drug 5 Administration approval, and SECTION 4: Emergency Department and Hospital Marijuana-Related Admissions Page | 77 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Pot-Related ER Visits Increase among Visitors to Colorado: In February 2017, Matt push Summit County to the top of the list for emergency room visits related to people Summit County reported 21 marijuana-related emergency room visits (per 1,000 people) from 2011-2013. In 2014-2015, that number increased to 56 visits per 1,000 people. Dr. Marc Doucette of St. Anthony Summit Medical Center stated, recent statistics released by the Colorado Department of Public Health and Environment, Doucette said, urprised to see that but it speaks to the fact that most of our population, especially in the ski season, are out-of-state patients and following the legalization of marijuana in the state in 2014. They say most of those cases 6 were patients visiting from outside of ER Visits for Kids Rise Significantly after Pot Legalized in Colorado: In 2017, quadrupled after marijuana was legalized in Colorado mostly for mental health Dr. George Sam Wang, a Colorado physician, was the lead researcher who authored a study which examined Colorado youth, marijuana use and associated emergency 639 teenagers who went to one hospital system in Colorado in 2015 had either cannabis in their urine of marijuana was legalized in Colorado In 2016 Wang found that the average rate of marijuana-related visits to the from nine in 2009 to 47 in 2015 risk has gone down qu 7 believe marijuana is safe SECTION 4: Emergency Department and Hospital Marijuana-Related Admissions Page | 78 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Mysterious Illness Tied to Marijuana Use on the Rise in States with Legal Weed: An Indianapolis physician recently diagnosed a condition in a patient, Lance Crowder, who had been experiencing severe abdominal pain and vomiting for over two years. None of the local physicians had been able to diagnose the problem, until now. Over the past several years there has been an increase in the number of emergency room visitors presenting with the same exact signs and symptoms as Lance, known as cannabinoid hyperemesis syndrome (CHS). Dr. Kennon Heard of Aurora, Colorado co-authored a study published in 2015 which showed that when medical marijuana became widely available, emergency room nly been recognized for about the past decade, and nobody knows exactly how many people suffer from it. But as more states move towards the legalization of marijuana, emergency room physicians like Dr. Heard are eager to make 8 sure both doctors and patients For Further Information on Emergency Department Visits and Hospitalizations See Page 155 SECTION 4: Emergency Department and Hospital Marijuana-Related Admissions Page | 79 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Sources 1 - <https://www.aapc.com/icd-10/faq.aspx>, accessed August 1, 2017. 2 -Median and Mean Expenses per Person With Expense and Distribution of Expenses by Source of Payment: United States 3 Kare-mail message, September 14, 2017. 4 Brad Roberts, MD-mail message, September 15, 2017. 5 Brad Roberts, MD, Marijuana May 15, 2017, <http://www.acepnow.com/article/dangers-marijuana-experienced-firsthand/>, accessed August 9, 2017. 6 Matt -Related ER Visits Increase Among Visitors To Co February 14, 2017, < http://denver.cbslocal.com/2017/02/14/pot-related-er-visits- increase-among-visitors/>, accessed September 12, 2017. 7 NBC News, May 5, 2017, <http://www.nbcnews.com/health/health-news/er- visits-kids-rise-significantly-after-pot-legalized-colorado-n754781>, accessed May 4, 2017. 8 rise in states with legal weed,KKTV/CBS, December 28, 2016, <http://www.kktv.com/content/news/Mysterious-illness-tied-to-marijuana-use-on-the- rise-in-states-with-legal-weed-408565045.html>, accessed August 2, 2017. SECTION 4: Emergency Department and Hospital Marijuana-Related Admissions Page | 80 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 SECTION 5: Marijuana-Related Exposure Some Findings Marijuana-related exposures increased 139 percen t in the four-year average (2013-2016) since Colorado legalized recreational marijuana compared to the four-year average (2009-2012) prior to legalization. Marijuana-related exposures in children (ages 0 to 5) nearly tripled in the four- year average (2013-2016) since Colorado legalized recreational marijuana compared to the four-year average (2009-2012) prior to legalization. For adults 26 years of age or older, nearly triple the amount of yearly marijuana- related exposures occurred in 2013-2016 as compared to 2009-2012. Marijuana only exposures more than doubled (increased 210 percent) in the four-year average (2013-2016) since Colorado legalized recreational marijuana compared to the four-year average (2009-2012) prior to legalization. Definitions Marijuana-Related Exposure: Any phone call to the Rocky Mountain Poison and Drug Center in which marijuana is mentioned. Marijuana Only Exposure: Marijuana was the only substance referenced in the call to the poison control center. Data SECTION 5: MarijuanaRelated Exposure Page | 81 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Average Number of Marijuana-Related Exposures, All Ages 201 250 200 150 84 59 100 50 139% 42% Increase Increase 0 2006-20082009-20122013-2016 Pre-CommercializationPost-CommercializationRecreational Legalization SOURCE: Rocky Mountain Poison and Drug Center Marijuana-Related Exposures 250 223 224 Legalization 231 200 Commercialization 127 150 117 110 101 95 86 92 100 70 6267 45 50 44 45 39 50 27 2626 21 0 20062007200820092010201120122013201420152016 Total Marijuana Cases 457062449586110127223231224 Youth (0-18) Cases 212626274539506792117101 SOURCE: Rocky Mountain Poison and Drug Center Report, Colorado Marijuana Statistics for 2016 SECTION 5: MarijuanaRelated Exposure Page | 82 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Average Marijuana-Related Exposures by Age Range 2006-20082009-20122013-2016 Pre-CommercializationPost-CommercializationLegalization 68 70 60 50 37 40 32 31 30 24 20 17 17 20 13 13 12 11 9 6 10 4 3 2 1 0 0-5yrs6-12yrs13-14yrs15-17yrs18-25yrs26+ yrs SOURCE: Rocky Mountain Poison and Drug Center Average Percent of All Marijuana-Related Exposures, Children Ages 0 to 5 Years Old NationalColorado 18.26% 20.00% 15.22% 18.00% 16.00% 14.00% 12.00% 7.07% 10.00% 6.78% 8.00% 4.66% 3.59% 6.00% 4.00% 2.00% 0.00% 2006-20092010-20122013-2016 SOURCE: Rocky Mountain Poison and Drug Center SECTION 5: MarijuanaRelated Exposure Page | 83 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Number of Marijuana Only* Exposures Reported 153 151 160 142 Legalization 140 120 88 100 Commercialization 80 61 53 60 40 37 34 32 40 27 29 2525 28 18 20 0 2001200220032004200520062007200820092010201120122013201420152016 *Marijuana was the only substance referenced in thecall to the poison control center SOURCE: Rocky Mountain Poison and Drug Center Case Examples 1 Rocky Mountain Poison and Drug Center: Caller asking if there is such thing as a withdrawal phenomenon with marijuana? Her daughter is home from college and she is having major anxiety since being home and not smoking her daily weed. She also wants to know if it hurt her brain while in college if she smokes regularly? She was advised that yes, withdrawal has been described after heavy use. And that yes, there could be effects to her brain. Caller concerned had out of town guests staying at her house. Made a favorite pie one day when they were out, and substituted marijuana oil for the normal amount of oil. She did not intend for her guests to eat her pie. Guests ate a significant amount one day when she was upstairs and developed paranoia, SECTION 5: MarijuanaRelated Exposure Page | 84 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Caller ate a couple marijuana gummys \[sic\] while at work, not knowing they were MJ-containing. Developed lightheadedness and dizziness, which resolved - Caller says her spouse ingested an edible containing THC and felt nauseous. Then took an OTC \[over the counter\] medicine to counteract the queasiness, and then felt worse (foggy, dizzy, confused). PC referred caller to an Emergency Colorado dog dazed and confused: In late 2016, Colorado resident Heidi Sodetz took her two golden retrievers for a run on Tenderfoot Mountain. According to the resident, one of the dogs began to act strangely approximately an hour after the run. Lenni was peed herself on the carpet, something she Silverthorne, CO to investigate what was happening. Based on the signs and symptoms, the local veterinarian was immediately suspicious of psychoactive ingredient in marijuana. According to the owner, who claims to not use that someone had dr were two additional dogs being treated for marijuana exposure at the same facility at 2 the same time. For Further Information on Exposures See Page 157 Sources 1 Rocky Mountain Poison and Drug Center, August 2017. 2 Summit Daily, <http://www.summitdaily.com/news/marijuana/in- colorado-marijuana-edibles-increasingly-sending-dogs-to-the-animal-er/>, accessed th September 12, 2017. SECTION 5: MarijuanaRelated Exposure Page | 85 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 THIS PAGE INTENTIONALLY LEFT BLANK SECTION 5: MarijuanaRelated Exposure Page | 86 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 SECTION 6: Treatment Some Findings Marijuana treatment data from Colorado in years 2006 2016 does not appear to demonstrate a definitive trend. Colorado averages 6,683 treatment admissions annually for marijuana abuse. Over the last ten years, the top four drugs involved in treatment admissions were alcohol (average 13,551), marijuana (average 6,712), methamphetamine (average 5,578), and heroin (average 3,024). Data Treatment with Marijuana as Primary Substance of Abuse, All Ages 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0 20062007200820092010201120122013201420152016 SOURCE: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Treatment Episode Data Set (TEDS) Based on administrative data reported by States to TEDS through July 6, 2017 SECTION 6: Treatment Page | 87 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Drug Type for Treatment Admissions, All Ages 16,000 14,000 12,000 s n o i s s 10,000 i m d A 8,000 f o r e b 6,000 m u N 4,000 2,000 0 200520062007200820092010201120122013201420152016 Alcohol 10,16811,72112,09413,38213,87313,29213,42214,83414,00814,38112,81013,415 Marijuana 5,5585,7086,1446,9007,0746,9036,6877,0566,8776,9076,2676,307 Meth 5,0815,0665,1094,9394,5434,4514,3615,0025,7236,9246,8597,871 Cocaine 2,9343,4813,4593,6853,0312,5212,3682,2761,7481,6571,4841,377 Heroin 1,5191,3691,3491,4871,7281,7852,2252,7463,2234,4915,0636,142 Prescription 7498751,0141,2741,5261,7341,9292,3452,2702,3061,7711,935 Other 32433042013112191125151152177192555 SOURCE: Colorado Department of Health Services, Office of Behavioral Health, 2005-2016 SECTION 6: Treatment Page | 88 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Percent of Marijuana Treatment Admissions by Age Group 60 50 s n o i s 40 s i m d 30 A f o t n 20 e c r e P 10 0 20062007200820092010201120122013201420152016 12-17 31.228.228.328.72927.724.122.419.818.822.5 18-20 1313.3131412.911.912.111.29.49.49.4 21-25 2020.219.620.220.519.920.520.922.421.319.2 26+ 35.838.339.137.137.640.543.345.548.750.548.8 SOURCE: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Treatment Episode Data Set (TEDS) Based on administrative data reported by States to TEDS through July 6, 2017 SECTION 6: Treatment Page | 89 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Marijuana Treatment Admissions Based on Criminal Justice Referrals Ages 17 and UnderAges 18-25 1,600 1,448 1,347 1,3071,328 1,320 1,400 1,291 1,287 1,2041,204 1,202 s n o 1,200 1,062 i s 1,238 s i 1,000 m d 1,0541,015 1,015 A 997 985 f 800 o r 826 821 805 e 706 600 b 660 m u 400 N 200 0 20052006200720082009201020112012201320142015 SOURCE: Colorado Department of Health Services, Office of Behavioral Health, 2005-2016 Comments from Colorado Treatment Providers Are S: Many patients minimize the consequences of cannabis use, yet they consistently report that they have become isolated, paranoid and unable to effectively interact with the outside world. In treatment, there has been a consistent increase in psychosis associated with patients who use cannabis. Thought broadcasting, thought insertion, ideas of reference and command hallucinations are not uncommon. These symptoms often occur in the absence of any other psychiatric disorder. The symptoms appear to decrease over time, with more time in recovery, but it is unclear whether the symptoms are long lasting. Since these symptoms are so 1 debilitating, it is crucial to learn more about the long term effects of cannabis use. : have definitely seen more cannabis use in the individuals I am treating. I've also seen an increasing number of young men coming into treatment with symptoms of mania, psychosis and dangerous behaviors associated with cannabis use. Their lives have been completely disrupted due to the cannabis use. Unfortunately, abstinence from the cannabis use alone is not enough to make the symptoms go away. They require mood stabilizing and anti-psychotic medications to get to a point that they can communicate SECTION 6: Treatment Page | 90 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 coherently enough and trust others enough to participate in therapy. I do think this is related to the increased availability and potency, and this is consistent with the scientific literature. On a personal note, my 10 and 11 year old children know what cannabis smoke smells like, identifying cannabis in the area rather than wondering if it is a skunk. Public use occurs everywhere. Children call each other, vapers, in their less kind moments, and children with anything green are made fun of. One of my 11 year old's friends since preschool was allegedly expelled for selling cannabis on the 5th grade 2 campus. As a parent, I'm terrified for the future of our children. : We recently reviewed data for patients receiving treatment in the residential portion of our substance abuse treatment center, CeDAR. What we found was that patients who met criteria for a cannabis use disorder were markedly younger than those that did not, were much more likely to have other substance use disorders (an average of 2.8 substance use disorder diagnoses vs 1.9 substance use disorder diagnoses when cannabis use disorder was excluded) and there was a trend towards more mental health pathology in this data set as well. Anecdotally, I and my colleagues have seen the number of patients with cannabis use disorder admitted to our facility increase over time. The amount of cannabis that patients describe consuming is also increasing, while the age they report first starting to use is decreasing. Overall the severity of cannabis use disorder we see appears more severe as do the psychosocial sequelae of this addiction. The link between psychosis and cannabis is well documented and it is becoming routine to admit young men who have used cannabis since early adolescence and who present with psychosis. Many of these patients may suffer long standing neuropsychiatric symptoms as the result of cannabis use. The burden of this illness is disproportionately falling on our younger 3 Case Examples Dr. Karen Randall, a practicing emergency medicine physician out of Pueblo, CO, described her first-hand experience of how marijuana has affected her community in Pueblo. Dr. Randall tells Vermont voters how of homeless and low income jobs where workers are a burden on the Medicaid system SECTION 6: Treatment Page | 91 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 ublic by some l an open petition in the paper in support of reversing the marijuana stance in \[Pueblo\] 4 issue before voting. For Further Information on Treatment See Page 157 Sources 1 Bari K Platter, MS, RN, PMHCNS-BC, Clinical Nurse Specialist, Center for Dependency, Addiction and Rehabilitation (CeDAR), University of Colorado Health, Aurora, Colorado, August 2016. 2 Laura F. Martin, M.D. Distinguished Fellow of the American Psychiatric Association, American Board of Addiction Medicine Diplomate Medical Director, Center for Dependency, Addiction and Rehabilitation (CeDAR), Associate Professor, Department of Psychiatry, University of Colorado School of Medicine, August 2016. 3 Ruth Marie Huhn, M.D., Board Certified Attending Psychiatrist at the Center for Dependency, Addiction and Rehabilitation (CeDAR), Instructor, Department of Psychiatry, University of Colorado School of Medicine, August 2016. 4 Dr. Karen Randall, VTDIGGER, https://vtdigger.org/2017/06/20/karen-randall- marijuana-legalization-colorado-community-member/#.WcFCX8KWy71> accessed September 19, 2017. SECTION 6: Treatment Page | 92 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 SECTION 7: Diversion of Colorado Marijuana Some Findings In 2016, RMHIDTA Colorado drug task forces completed 163 investigations of individuals or organizations involved in illegally selling Colorado marijuana both in and out of state. o These cases led to: 252 felony arrests 7,116 pounds (3.5 tons) of marijuana seized 47,108 marijuana plants seized 2,111 marijuana edibles seized 232 pounds of concentrate seized 29 different states to which marijuana was destined Highway interdiction seizures of Colorado marijuana increased 43 percent in the four-year average (2013-2016) since Colorado legalized recreational marijuana compared to the four-year average (2009-2012) prior to legalization. Highway interdiction seizures of Colorado marijuana increased 20 percent from 288 in 2013, when recreational marijuana was legalized, to 346 in 2016. Of the 346 highway interdiction seizures in 2016, there were 36 different states destined to receive marijuana from Colorado. o The most common destinations identified were Illinois, Missouri, Texas, Kansas and Florida. o Approximately half of all seizures (48 percent) containing Colorado marijuana originated from Denver. SECTION 7: Diversion of Colorado Marijuana Page | 93 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Definitions Colorado Marijuana Investigations: RMHIDTA Colorado drug task forces investigating individual or organizations involved in illegally selling Colorado marijuana, both within and outside of the state. These investigations only include those reported by the ten RMHIDTA drug task forces. Colorado Marijuana Interdictions: Incidents where state highway patrol officers stopped a driver for a traffic violation and subsequently found Colorado marijuana destined for other parts of the country. These interdiction seizures are reported on a voluntary basis to the National Seizure System (NSS) managed by the El Paso Intelligence Center (EPIC). These are random traffic stops, not investigations, and do not include local law enforcement data. A Colorado document contained the following statement in one of their Data prior to 2014 is not comparative due to changes in the reporting. The RMHIDTA began entering seizure data into the NSS beginning January 1, 2014 and that resulted in a spike of seizures being reported. There has not been a discernable upward trend in seizures since retail sales began in This statement is inaccurate and misleading. The data used in the Rocky Mountain HIDTA report is only highway patrol seizures and not from any of the task forces or drug units. This is the same dataset that RMHIDTA has been using since 2005. SECTION 7: Diversion of Colorado Marijuana Page | 94 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Data on Marijuana Investigations NOTE: T HE CHARTS ONLY INCLUDE COMPLETED INVESTIGATIONS REPORTED BY THE TEN RMHIDTA DRUG TASK FORCES. I T IS UNKNOWN HOW MANY OF THESE TYPES OF INVESTIGATIONS WERE COMPLETED BY NON-RMHIDTA DRUG UNITS OR TASK FORCES. The RMHIDTA drug task force unit commanders feel that the Colorado marijuana investigations completed in 2016 only impacted a relatively small portion of actual operations involved in illegally selling Colorado marijuana both in and out of state. In 2016, ten RMHIDTA Colorado drug task forces completed 163 investigations of individuals or organizations involved in illegally selling Colorado marijuana both within and outside of the state. The task forces seized approximately 3.5 tons of marijuana; 47,108 plants; 2,111 edibles; and 232 pounds of concentrate. There were 252 felony marijuana arrests and 29 different states identified as to where the Colorado marijuana was being sent. RMHIDTA Colorado Task Forces: Marijuana Investigation Seizures 10,000.00 d e 7,115.61 8,000.00 z i e S 6,000.00 s d 4,000.00 n u o 1,489.53 1,028.62 2,000.00 P 425.00 0.00 2013201420152016 SOURCE: Rocky Mountain HIDTA Performance Management Process (PMP) Data SECTION 7: Diversion of Colorado Marijuana Page | 95 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 RMHIDTA Colorado Task Forces: Marijuana Investigative Plant Seizures d e z i 60,000 e 47,108 S 50,000 s t n 40,000 a l P 30,000 f o 14,979 20,000 r e 7,290 5,215 b 10,000 m u 0 N 2013201420152016 SOURCE: Rocky Mountain HIDTA Performance Management Process (PMP) Data Marijuana Concentrate Seizures o 2016: 232.12 pounds of hash oil (1,099 percent increase from 2015). o 2015: 19.36 pounds of hash oil. o Data not collected prior to 2015. Marijuana Edible Seizures o 2016: 2,111 individual edible items (633 percent increase from 2015). o 2015: 288 individual edible items. o Data not collected prior to 2015. RMHIDTA Colorado Task Forces: Marijuana Investigative Felony Arrests 300 s 252 t s e 250 r r A 200 f 138 130 o 150 r e 81 b 100 m u 50 N 0 2013201420152016 SOURCE: Rocky Mountain HIDTA Performance Management Process (PMP) Data SECTION 7: Diversion of Colorado Marijuana Page | 96 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Data on Highway Interdictions NOTE: T HE CHARTS ONLY INCLUDE CASES WHERE C OLORADO MARIJUANA WAS ACTUALLY SEIZED AND REPORTED. I T IS UNKNOWN HOW MANY C OLORADO MARIJUANA LOADS WERE NOT DETECTED OR, IF SEIZED, WERE NOT REPORTED. A 2014 survey of approximately 100 interdiction experts estimates that 10 percent or less of marijuana being trafficked is ceased by state highway patrol agencies. Average Colorado Marijuana Interdiction Seizures 347 350 242 300 250 200 150 52 100 50 43% Increase 365% Increase 0 2006-20082009-20122013-2016 Pre-CommercializationPost-CommercializationLegalization SOURCE: El Paso Intelligence Center, National Seizure System, as of August 28th, 2017 SECTION 7: Diversion of Colorado Marijuana Page | 97 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Colorado Marijuana Interdiction Seizures 450 Legalization 394 400 360 346 350 321 288 281 300 274 Commercialization 250 200 150 92 100 5458 57 41 50 0 200520062007200820092010201120122013201420152016 SOURCE: El Paso Intelligence Center, National Seizure System, as of August 28th, 2017 Average Pounds of Colorado Marijuana from Interdiction Seizures 3,627 4,000 2,515 3,500 3,000 2,500 2,000 1,500 1,000 500 44% Increase 0 2006-2008 Pre-2009-2016 Post- CommercializationCommercialization SOURCE: El Paso Intelligence Center, National Seizure System, as of August 28th, 2017 In the four years (2013-2016) of legalized recreational marijuana in Colorado, highway patrol seizures have resulted in over 6 tons of Colorado marijuana being seized (12,873 pounds). SECTION 7: Diversion of Colorado Marijuana Page | 98 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 States to which Colorado Marijuana was Destined, 2016 (Total Reported Incidents per State) There were 15 seizures for which the destination was unknown. Top Three Cities for Marijuana Origin Number of Seizures Originating City from Percent Rank Originating City 1. Denver 166 48% 2. Colorado Springs 34 10% 3. Aurora 13 4% * Of the 346 seizures, only 283 seizures had an origin city identified. The numbers above represent the top three cities from which Colorado marijuana originated. The percent was calculated from known origin cities. SOURCE: El Paso Intelligence Center, National Seizure System, as of August 28th, 2017. SECTION 7: Diversion of Colorado Marijuana Page | 99 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Case Examples of Investigations NOTE: T HE EXAMPLES BELOW ARE ONLY A SMALL SAMPLE OF THE MANY INVESTIGATIONS INVOLVING C OLORADO MARIJUANA CITED BY VARIOUS DRUG UNITS. Dozens of Indictments in Largest Illegal Marijuana Trafficking Ring Bust since Legalization: Colorado Attorney General Cynthia Coffman announced that the largest illegal marijuana trafficking investigation has resulted in arrests in late June of 2017. The trafficking organization spanned five states, and the investigation resulted in 62 people having files charged against them. More than 20 law enforcement organizations were involved in the investigation and/or takedown which included the Denver Police Department and the U.S. Drug Enforcement Administration. According to Coffman, this single investigation is a prime example of how the marijuana black market continues to flourish in Colorado. During raids, agents seized 2,600 marijuana plants and another 4,000 lbs. of marijuana. As a whole, the trafficking ring produced an estimated 100 lbs. of marijuana a month, which is sold for approximately $2,000 per pound on the black market in 1 Colorado. Scott Pack was indicted by Colorado grown marijuana across state lines ended in the indictment of sixteen people. Among those indicted was Renee Rayton, a former Marijuana Enforcement Division employee. rijuana companies in Colorado. They own a significant number of licenses, and through a series of shell companies, In the Westword article published June of 2017, Buck continued to describe the details 2 Arrests Made in South Pueblo County Marijuana Grow: According to a press release th ee individuals were arrested on April 13, 2016 in connection with an illegal marijuana grow operating from within a Pueblo, CO home. In total, 180 marijuana plants were found growing in the home being occupied by the three individuals. The three individuals had been living in Florida, but were originally from Cuba. One of the three individuals had recently purchased the home in February of 2016. SECTION 7: Diversion of Colorado Marijuana Page | 100 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Although the press release did not specifically state that the marijuana was being illegally trafficked outside the state, several indicators suggest that the marijuana was intended to leave Colorado. Twelve people, all from Florida, have been arrested in seven separate illegal marijuana grow operations discovered in Pueblo County on thth March 30 and April 14, 2016. Five of the twelve individuals were originally from 3 Cuba. Individuals Indicted for an Illegal Home-grow Also Possess Legal Marijuana Licenses: In March 2017, 16 people were indicted for participating in a massive illicit marijuana home-grow operation. Of the 16, eight are recorded as having active or expired licenses to work in the legal marijuana business including the ringleader, Michael Alan Stonehouse, who acts as a consultant for the marijuana industry in Colorado. According to authorities, the group cultivated their marijuana in properties in Colorado Springs, Castle Rock, Elbert County and Denver and then diverted the 4 marijuana to Illinois, Arkansas, Minnesota and Missouri to make a higher profit. All in the Family Marijuana Operation: Weld County Drug Task Force received a crime tip that a family was involved in cultivating and distributing marijuana from properties located in Weld County. Information was that they were shipping the search warrant was served on the rural properties of the father and mother where officers discovered 101 marijuana plants and marijuana in vacuum sealed bags. However, the mother and father were able to show they had medical marijuana licensing allowing them to have 50 marijuana plants each and 16 ounces of edibles. A -in- documentation and led to the seizure of 379 marijuana plants, 70 pounds of marijuana, the scene and arrested for having multiple pounds of dried marijuana in vacuum sealed 5 containers and edibles hidden in his vehicle. Laotian Marijuana Operation: Southern Colorado Drug Task Force managed by DEA began an investigation of a Laotian drug trafficking organization that had relocated to Colorado from Arkansas and California. This organization had 12 different cultivation marijuana sites located in 5 different counties in southeast Colorado. Task force officers served search warrants seizing 2,291 marijuana plants, 2,393 pounds of processed 5 marijuana. Also seized were 4 hand guns and 6 long guns. Rental House Remodel: In February 2016, Western Colorado Drug Task Force arrested two Cubans from Florida for illegally growing marijuana for distributions. These two rented a $750,000 house and modified it to cultivate marijuana at a cost of about SECTION 7: Diversion of Colorado Marijuana Page | 101 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 $50,000. Both subjects obt 63), 5 equipment for a butane hash-oil lab and a hand gun. Florida and Colorado Connection: Southern Colorado Drug Task Force managed by DEA executed search warrants in the Pueblo area targeting a drug trafficking organization that had relocated from Florida to Colorado for sole purpose of setting up a large scale marijuana grow operation. As a result of a search warrant, officers seized 1,900 marijuana plants, 17 pounds of processed marijuana, 2 butane hash oil extraction labs and 9 fire arms. There was an independent seizure in Texas that the group was responsible for which included 12 pounds of marijuana and marijuana shatter. The 5 search warrant resulted in 7 arrests. Marijuana and Guns: Southwest DTF with DEA targeted a drug trafficking organization responsible for cultivation and distribution of hundreds of pounds of marijuana outside the state of Colorado. Search warrants were served on a number of residents where officers discovered marijuana cultivation as well as 480 pounds of 5 documents. Large BHO Lab Seized: West Metro Drug Task Force served a search warrant on a residence in Jefferson County. Officers seized 2 large butane hash oil labs along with 5 five-gallon butane tanks, 271 marijuana plants, hash and numerous guns. Officers also discovered documentation confirming the distribution of hash and marijuana to 5 Florida. Florida Cuban Drug Trafficking Organization: In May 2016, Southern Colorado Drug Task Force executed search warrants at 5 different residential locations operated by a group of Cubans from Florida. These grow operations were in Pueblo County and offices seized a total of 214 marijuana plants, 55 pounds of processed marijuana and 5 over $100,000 in grow equipment. Mississippi Connection: In August 2016, Western Colorado Drug Task Force arrested two suspects from Mississippi who recently moved to Colorado to cultivate marijuana and to distribute it back to Mississippi. They rented an upscale house and made major modifications including theft of electrical power. About 50 percent of the living space of the home was used to cultivate marijuana. Agents seized 306 marijuana plants and turned the three young children who were living in the house over to Child Protective 5 Services. SECTION 7: Diversion of Colorado Marijuana Page | 102 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Marijuana Bust in Northeast Colorado Springs: In July of 2017, federal agents hauled at least 180 marijuana plants out of a private residence in northeast Colorado Springs. Although authorities did not disclose many details of the investigation, they did disclose that one person was taken into custody, and that they had prior knowledge of the illegal marijuana grow inside the home. The home was currently being rented, and t stated whether or not marijuana was being trafficked outside of Colorado, but a 180 marijuana plant operation is certainly enough to contribute significantly to an illegal 6 trafficking operation. Colorado Deputy Onion Load: southeastern Colorado made an interesting discovery. The truck was pulled over after remaining in the passing lane while traveling from Brighton, CO to Naples, Florida. The driver of the vehicle consented to the search of the vehicle after the deputy issued a warning for the driving infraction. Upon further investigation, the deputy found over 180 lbs. of marijuana mixed in among a load of onions being hauled by a tractor-trailer. In total, there were three trash bags containing marijuana, and eight packages of plastic 7 wrapped marijuana concealed in the trailer. Case Examples of Interdictions Tractor-Trailer Marijuana Transport: May 2017, Florida Highway Patrol stopped a semi-truck and trailer traveling southbound through Alachua, FL. Upon search of the vehicle, 170 lbs. of marijuana was located and seized by state troopers. The vehicle was 8 traveling from Colorado to Florida. Motorhome Carrying 100 Pounds of Pot Seized in Tennessee: In August of 2016, a Tennessee Highway Patrol trooper pulled over a vehicle after observing several indicators of possible criminal activity. After requesting backup and obtaining permission to search the vehicle, law enforcement officials found several duffel bags and boxes filled with marijuana. The various containers of marijuana were located in the bedroom area of the motorhome. In total, the various bags and boxes contained approximately 100 pounds of illegally trafficked marijuana. The driver admitted that he 9 obtained the marijuana in Colorado and he was headed to Florida. Texas DPS Seizes Load Destined for Florida: January 2016, the Texas Department of Public Safety stopped a passenger van traveling southbound US-81. The state trooper SECTION 7: Diversion of Colorado Marijuana Page | 103 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 developed reasonable suspicion of criminal activity, and searched the vehicle based on verbal consent provided by the driver. Upon search of the vehicle, over 72 lbs. of marijuana was located in the vehicle. The trip originated in Colorado Springs, CO and 8 was destined for Jacksonville, Florida. Reckless Driving Leads to Over 76 lbs of Marijuana: February 2016, Colorado State Patrol stopped a vehicle due to several public complaints of reckless driving. Initially, the driver of the vehicle would not pull over, but eventually pulled to the side of the road. Upon further investigation, the trooper discovered over 76 lbs. of marijuana and 8 the driver was a Florida resident. Colorado Marijuana Variety Headed to Illinois: April 2017, two Illinois residents who recently left Colorado were stopped by Nebraska State Patrol while speeding eastbound along I-80. Upon contact with the driver and passenger, the smell of marijuana was immediately detected by the state trooper. After both occupants admitted that there was marijuana in the vehicle, a thorough search was conducted. Over 4 ounces of marijuana, a limited amount of hash oil infused marijuana, 161 THC infused edibles, marijuana seeds, THC vaporizer oil cartridges, marijuana wax and several items of 8 paraphernalia were discovered in the vehicle. Illinois: May 2017, a Dodge Charger was stopped for speeding while traveling eastbound along I-80 in Nebraska. The smell of marijuana was immediately detected as the state trooper approached the vehicle. Upon a probable cause search, the four Illinois residents inside the vehicle were found to be in possession of approximately 1.5 lbs. of d other 8 items of paraphernalia. Indiana : April 2017, a Kansas Highway Patrol Trooper stopped a vehicle traveling from Colorado to Indiana with THC marijuana items and a loaded .40 caliber handgun. The suspect claimed all the marijuana was for the consumption of those within the vehicle, and he went on to explain g marijuana since he 8 was a kid. Colorado Marijuana to Iowa: February 2016, Colorado State Patrol stopped a vehicle traveling from Brighton, Colorado to Des Moines, Iowa. The stop resulted in the arrest of the driver from Des Moines, Iowa, passenger from Clearlake, Iowa and the seizure of SECTION 7: Diversion of Colorado Marijuana Page | 104 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 8 lbs. of marijuana, 85.05 grams marijuana concentrate, and a S/W M&P 9mm handgun. The vehicle was initially stopped for a signal violation. The marijuana was located 10 inside a large clothing duf Colorado Marijuana Plants to Kentucky: May 2017, a vehicle was stopped in eastern Colorado while traveling eastbound from Boulder, Colorado to Lexington, Kentucky. After the driver provided his consent to search the vehicle, Colorado State Patrol 8 located 288 individual marijuana plants inside the vehicle. Colorado Marijuana to Maryland: November 2016, an Ohio State Highway Patrol Trooper stopped a vehicle traveling eastbound along I-80. The driver was a Colorado resident traveling to Maryland. After the driver displayed several indications of criminal activity, a canine was allowed to p canine alerted to the presence of an illegal substance. After a thorough search, law enforcement found a variety of cannabis products in the vehicle (chocolate bars, gummies, etc.). Upon questioning, the drive 11 legal to have marijuana. Maryland: June 2017, an Ohio State Highway Patrol Trooper stopped a car-hauler traveling eastbound along I-70. Upon investigation, the State Trooper became suspicious of both vehicles being transported on the car-hauler. After driver consent and a subsequent external canine search, a probable cause search was performed and approximately 5 lbs. of marijuana along with 108 vials of liquid THC were discovered in one of the vehicles being transported. The vehicle was being shipped from Denver, Colorado to Bethesda, Maryland. There were no indications that the driver of the car- 12 hauler knew he was illegally transporting marijuana. Minnesota Medical Marijuana for Distribution: April 2017, a vehicle was stopped while traveling eastbound along I-80 in North Platte, Nebraska. The driver immediately claimed to be a medical marijuana patient who had been diagnosed with multiple sclerosis. Upon further investigation, the driver was found to be in possession of a substantial amount of marijuana, THC liquid vials, and other edible THC products that were packaged in a way that made the state trooper suspicious that the marijuana was intended for distribution. Several of the bags of THC edibles were actually labeled with the marijuana infused products. The vehicle was traveling from Colorado to 8 Minnesota. Destination Unknown: March 2017, Missouri State Highway Patrol stopped a vehicle from Colorado which was southbound I-29. The Colroado driver would not discolse SECTION 7: Diversion of Colorado Marijuana Page | 105 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 where he was traveling to. After several indicators of criminal behavior were noted, a search of the vehicle yielded 26 lbs. of marijuana concelaed inside a red duffel bag on 13 the back seat. Missouri: May 2017, Kansas Highway Patrol stopped a car hauler traveling from Denver, Colorado to Missouri. A subsequent search of one of the vehicles being hauled 14 yielded 50 lbs. of high-grade marijuana. New York Distribution: January 2016, Ohio State Patrol stopped a vehicle traveling eastbound along I-70 in Madison County, Ohio. After displaying suspicious behavior when interacting with the state trooper, a canine search was performed on the vehicle. The canine indicated a positive response on the vehicle, and a full search ensued. During the search, 123 lbs. of marijuana were discovered in rubber totes in the rear storage area of the vehicle along with a vacuum sealer machine. The vehicle was 8 traveling from Colorado to New York. Flying to Buy Colorado Marijuana: April 2016, a Kansas Highway Patrol Trooper stopped an eastbound vehicle traveling along I-70. Upon investigation, the sole occupant was found to be in possession of 4.3 lbs. of marijuana, 158 marijuana edibles, and 8 ounces of a THC infused drink. The driver had flown from his home in Pennsylvania and through a third-party had obtained a one way rental from Aurora, Colorado. After buying the recreational marijuana products, the driver was 8 transporting the product to his home state (Pennsylvania). Note: Flying to Colorado and driving back home is a common method for illegally transporting marijuana out of state. South Carolina Dealer Uses Rental Vehicle: March 2017, Kansas Highway Patrol stopped a vehicle traveling eastbound along I-70 in Goodland, Kansas. After a short roadside investigation, the driver of the vehicle was found to be in possession of 13 lbs. of marijuana, 101 THC vapor cartridges, and 378 fl. oz. of THC infused beverages (20 individual drinks). The driver had rented the vehicle four days prior. He had driven from South Carolina to Colorado, and was headed back to South Carolina when he had 8 been stopped in Kansas. Note: Rental vehicles are commonly used to buy and transport Colorado marijuana out of state. Marijuana and Concentrate to Iowa: In February 2017, Kansas Highway Patrol stopped a vehicle traveling from Loveland, Colorado to Iowa. A search of the vehicle yielded 25 15 lbs. of marijuana and 1 lb. of THC shatter. SECTION 7: Diversion of Colorado Marijuana Page | 106 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Sources 1 illegal marijuana trafficking ring KDVR-TV Channel 2 Denver, June 28, 2017, <http://kdvr.com/2017/06/28/62-people-12-businesses-indicted-in-largest-illegal- marijuana-ring-bust-in-colorado-history/>, accessed June 28, 2017. 2 Westword, June 14, 2017, <http://www.westword.com/news/scott- pack-indicted-in-huge-colorado-marijuana-fraud-case-9156890>, accessed August 11, 2017. 3 Pue accessed July 26, 2017. 4 ng operation The Denver Post, March 24, 2017, <http://www.denverpost.com/2017/03/24/denver-marijuana-smuggling-operation- medical-marijuana-licenses/http://www.denverpost.com/2017/03/24/denver-marijuana- smuggling-operation-medical-marijuana-licenses/>, accessed April 19, 2017. 5 Rocky Mountain HIDTA Task Force Quarterly Reports, Calendar Year 2016-2017. 6 July 12, 2017, <http://www.kktv.com/content/news/DEA-search-warrant-in--434154383.html>, accessed July 26, 2017. 7 - The Denver Post, December 8, 2016, <http://www.denverpost.com/2016/12/08/colorado-deputy-finds-180-pounds-of- marijuana-mixed-in-with-tractor-trailers-onion-load/>, accessed December 8, 2016. th 8 El Paso Intelligence Center, National Seizure System. Data pull August 28, 2017. 9 August 28, 2016, <http://www.denverpost.com/2016/08/28/motorhome-100- pounds-marijuana-seized-tennessee/>, accessed August 28, 2016. SECTION 7: Diversion of Colorado Marijuana Page | 107 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 10st RMHIDTA Quarterly Report. Colorado Criminal Interdiction, 1 Quarter 2016. 11 Ohio State Highway Patrol Report of Investigation, via e-mail dated July 31st, 2017; accessed August 1st, 2017. 12 Ohio State Highway Patrol Report of Investigation, via e-mail dated July 13th, nd 2017; accessed July 22, 2017. 13 Midwest HIDTA Interdiction Bulletin 2017-47. 14 Midwest HIDTA Interdiction Bulletin 2017-84. 15 Midwest HIDTA Interdiction Bulletin 2017-26. SECTION 7: Diversion of Colorado Marijuana Page | 108 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 SECTION 8: Diversion by Parcel Some Findings Seizures of Colorado marijuana in the U.S. mail has increased 844 percent from an average of 52 parcels (2009-2012) to 491 parcels (2013-2016) in the four-year average that recreational marijuana has been legal. Seizures of Colorado marijuana in the U.S. mail has increased 914 percen t from an average of 97 pounds (2009-2012) to 984 pounds (2013-2016) in the four-year average that recreational marijuana has been legal. Data from U.S. Postal Service NOTE: T HESE FIGURES ONLY REFLECT PACKAGES SEIZED; THEY DO NOT INCLUDE PACKAGES OF C OLORADO MARIJUANA THAT WERE MAILED AND REACHED THE INTENDED DESTINATION. I NTERDICTION EXPERTS BELIEVE THE PACKAGES SEIZED WERE JUST THE TIP OF THE ICEBERG Average Number of Parcels Containing Marijuana Mailed from Colorado to Another State 491 500 400 300 52 200 100 844% Increase 0 (2009-2012)(2013-2016) Pre-Recreational LegalizationPost-Recreational Legalization SOURCE: United States Postal Inspection Service, Prohibited Mailing of Narcotics SECTION 8: Diversion by Parcel Page | 109 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Parcels Containing Marijuana Mailed from Colorado to Another State 1000 854 800 Legalization 581 600 320 400 207 158 200 0 36 15 0 20092010201120122013201420152016 SOURCE: United States Postal Inspection Service, Prohibited Mailing of Narcotics Average Pounds of Colorado Marijuana Seized by the U.S. Postal Inspection Service 984 1000 800 600 97 400 200 914% Increase 0 (2009-2012)(2013-2016) Pre-Recreational LegalizationPost-Recreational Legalization SOURCE: United States Postal Inspection Service, Prohibited Mailing of Narcotics SECTION 8: Diversion by Parcel Page | 110 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Pounds of Colorado Marijuana Seized by the U.S. Postal Inspection Service 1,725.51 1800 1600 Legalization 1,247.00 1400 1200 1000 800 493.05 469.91 600 262.00 400 57.20 68.20 0 200 0 20092010201120122013201420152016 SOURCE: United States Postal Inspection Service, Prohibited Mailing of Narcotics Number of States Destined to Receive Marijuana Mailed from Colorado Legalization 41 45 40 38 40 33 35 29 30 24 25 20 15 10 10 5 0 0 20092010201120122013201420152016 SOURCE: United States Postal Inspection Service, Prohibited Mailing of Narcotics SECTION 8: Diversion by Parcel Page | 111 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Private Parcel Companies There are courier delivery service companies, with locations throughout the country, from which Colorado marijuana destined for other states has been seized. Unlike the U.S. Postal Service, a central data system does not exist for these various private couriers. Several HIDTA regions were asked about parcel interdictions of marijuana from Colorado during calendar year 2016. The following data were provided by those HIDTA regions, although they do not represent 100% reporting for any state or region: Chicago: There were a total of 23 separate parcel interdictions in which Colorado marijuana, edibles, and/or marijuana concentrates (THC/wax) were seized by law enforcement. Totaling more than 47 lbs. of product, Chicago region law enforcement estimates the street value of products seized to be approximately $420,000. Houston: 6 packages of Colorado marijuana, weighing 5.3 lbs. Midwest: 18 packages of Colorado marijuana weighing 9.3 lbs. North Florida: 25 packages of Colorado marijuana, hashish and concentrated THC were seized, totaling 64 lbs. Ohio: 15 packages of Colorado marijuana, hash oil, concentrated THC wax and edibles were seized, weighing approximately 30 lbs. Washington/Baltimore: 25 packages containing over 37 lbs. of Colorado marijuana and/or THC concentrates were seized. Rocky Mountain: (packages destined outside of Colorado) 75 packages in total, which included 132 lbs. of marijuana products, and 89 individual edible products (brownies, candies, bars, etc.), and 6 live plants. When asked where the packages were destined, it was reported that these marijuana packages are being shipped all over the United States and out of the country. The furthest destination noted was the United Kingdom. SECTION 8: Diversion by Parcel Page | 112 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Case Examples From the Mountains to the Beach: In March of 2016, over 11 lbs. of high-grade marijuana was seized as it was being transported by FedEx Express. The marijuana was 1 sent from Aspen, Colorado to Neptune Beach, Florida. $12,000 Worth of Marijuana in the Mail: In December of 2016, over 6 lbs. of marijuana was seized as it was being transported by United Parcel Service (UPS). The marijuana 1 was mailed from Grand Junction, Colorado to Riviera Beach, Florida. Longmont, CO: In January of 2017, over 6.5 lbs. of high-grade marijuana were seized as it was being transported by FedEx Express. The marijuana 1 was mailed from Longmont, Colorado to Jacksonville Beach, Florida. In March of 2017, 13 lbs. of high-grade marijuana was seized as it was being transported by UPS. The marijuana was mailed 1 from Evergreen, Colorado to Atlantic Beach, Florida. Headed to the Atlantic: In June of 2017, over 8.5 lbs. of high-grade marijuana was seized as it was being transported by FedEx Ground. The marijuana was sent from 1 Littleton, Colorado to Jacksonville Beach, Florida. Arvada Man Gets One Year in Prison for Mailing Edibles: On February 18, 2017, 27 year-old Stephen Paul Anderson was sentenced to serve a year and one day in federal prison and three years of community supervised release for sending boxes of illegal marijuana edibles through the U.S. Postal Service. Anderson, who moved from Texas to Colorado, was manufacturing highly concentrated THC oil in his basement using an open flame fueled by a propane tank. This method of extracting oil has led to multiple 2 fires and explosions throughout the Denver area. Seizure of Marijuana-Filled Parcels Increasing: Police Chief Aaron Jimenez (St. Ann Police, Missouri) was recently interviewed by a St. Louis news media outlet. The article mentionedof high-grade marijuana are being shipped to the St. Louis area Jimenez explained how it was not always that way U.S. Postal Inspector Dan Taylor said, St. Louis area, our postal inspectors have seized over 1,200 pounds of marijuana, from the mail, in the last year. SECTION 8: Diversion by Parcel Page | 113 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 amount of seized marijuana equates to over 32 pounds a day. 3 Second Bust of Illegal Grow, Same Two People Arrested on the Same Property: Nearly 150 marijuana plants, packaged marijuana and firearms were seized from a property that has been busted before for illegally growing marijuana. The two arrested were the same two busted nearly a year ago. operation, agents from the Drug Enforcement Administration assisted with the investigation and seizure of the marijuana plants, cash, grow equipment, and four firearms. Of note, investigators found several packages of processed marijuana located in numerous United States Postal Services boxes, which appeared to be nearly ready to ship. According to the August article published by KKTV, the Colorado Springs news The DEA estimates there was between $25,000 to $30,000 worth of lighting equipment inside the single grow house. The marijuana seized has an estimated value 4 greater than $125,000. Home Improvement Goods: In November of 2016, the North Metro Task Force (NMTF) intercepted a package to be shipped via UPS that contained 18.5lbs of marijuana packaged in a Home Depot bucket. The package was being shipped to an address in 5 Stanley, North Carolina. The investigation has resulted in the arrest of two suspects. Heading South: In November of 2016, the North Metro Task Force (NMTF) intercepted a UPS shipment that contained 7.5lbs of marijuana and marijuana edibles. The two 5 packages within the shipment were addressed to Dallas, Texas, and Magnolia, Texas. April Fools Delivery: In April of 2017, the North Metro Task Force (NMTF) intercepted a package shipped via UPS that contained over 23lbs of marijuana. The package was being shipped to an address in Malden, Massachusetts. With the help of the Malden Police Department, a coordinated investigation took place which resulted in the arrest 5 of a single suspect. SECTION 8: Diversion by Parcel Page | 114 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Sources 1 North Florida HIDTA Information Bulletins, Package Interdiction Summaries. th Received July 25, 2017. 2 The Denver Post, February 22, 2017, <http://www.denverpost.com/2017/02/22/arvada-man-usps-marijuana-edibles/>, accessed April 19, 2017. 3 Fox 2 Now/St. Louis, June 17, 2017, <http://fox2now.com/2014/06/17/seizure-of-marijuana-filled- parcels-increasing/>, accessed August 17, 2017. 4nd Khloe Keeler, bust of illegal grow, same 2 people arrested on the same KKTV/11 News, August 8, 2017, <http://www.kktv.com/content/news/Illegal-grow-bust-guns-and-marijuana-seized-in- El-Paso-County-438387943.html>, accessed August 10, 2017. 5 Rocky Mountain HIDTA Task Force Quarterly Reports, Calendar Year 2016-2017. SECTION 8: Diversion by Parcel Page | 115 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 THIS PAGE INTENTIONALLY LEFT BLANK SECTION 8: Diversion by Parcel Page | 116 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 SECTION 9: Related Data Topics Crime Revenue Homeless Suicides THC Potency Marijuana Use and Alcohol Consumption Medical Marijuana Registry Licensed Marijuana Businesses Business Comparisons Demand and Market Size Reported Sales of Marijuana Price of Marijuana Local Response to the Medical and Recreational Marijuana Industry in Colorado NOTE: S OME OF THE DATA REPORTED IN THIS SECTION IS BECAUSE THERE HAVE BEEN SO MANY INQUIRIES ON THE PARTICULAR SUBJECT, SUCH AS CRIME AND SUICIDES. T HIS IS NOT TO INFER THAT THE DATA IS DUE TO THE LEGALIZATION OF MARIJUANA. Some Findings Crime in Denver increased 17 percent and crime in Colorado increased 11 percent from 2013 to 2016. Colorado annual tax revenue from the sale of recreational and medical marijuana was 0.8 percent s total statewide budget (FY2017). As of June 2017, there were 491 retail marijuana stores in the state of Colorado compared to 392 Starbucks and 208 . 66 percent of local jurisdictions have banned medical and recreational marijuana businesses. SECTION 9: Related Data Page | 117 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Crime Colorado Crime 160,000 140,000 120,000 100,000 80,000 60,000 40,000 20,000 0 200820092010201120122013201420152016 Property Crimes 132,212131,141132,623131,800136,483138,275133,927141,634149,713 Violent Crimes 41,91443,68043,58943,87544,20945,58347,91151,47854,052 SOURCE: Colorado Bureau of Investigation, http://crimeinco.cbi.state.co.us/ From 2009 to 2012 From 2013 to 2016 Colorado Crime Property Crime Increased 4.1% Increased 8.3% Violent Crime Increased 1.2% Increased 18.6% All Crime Increased 3.4% Increased 10.8% SOURCE: Colorado Bureau of Investigation, http://crimeinco.cbi.state.co.us/ SECTION 9: Related Data Page | 118 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 City and County of Denver Crime Property CrimesViolent Crimes 34,168 *2016 10,699 33,714 *2015 10,566 31,534 *2014 10,103 32,078 *2013 8,722 32,553 2012 7,255 31,719 2011 6,881 29,551 2010 6,655 30,371 2009 6,604 05,00010,00015,00020,00025,00030,00035,00040,000 Number of Crimes *In May 2013 the Denver Police Department implemented the Unified Summons and Complaint (US&C) process. This process unifies multiple types of paper citations, excluding traffic tickets, into an electronic process. That information is transmitted to the Denver Sheriff, County Court, City Attorney and District Attorney through a data exchange platform as needed. As a result of this process a reported offense is generated which was previously not captured in National Incident Based Reporting System (NIBRS). SOURCE: City and County of Denver, Denver Police Department, Crime Statistics and Maps, April 2016 SECTION 9: Related Data Page | 119 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Crime in Denver (City and County) 2013 2014 2015 2016 *All Reported Crimes 55,115 61,276 64,317 64,736 (To include all categories listed below) From 2013 to 2016 *Denver Crime Crimes Against Persons Increased 23% Crimes Against Property Increased 7% Crimes Against Society Increased 62% All Other Offenses Increased 30% All Denver Crimes Increased 17% * Actual number of crimes in Denver (new process began in May 2013) SOURCE: City and County of Denver, Denver Police Department, Crime Statistics and Maps, April 2016 Denver Police Department Unlawful Public Display/Consumption of Marijuana 770 762 800 590 700 600 500 400 184 300 200 8 100 0 20122013201420152016 SOURCE: Denver Police Department, Traffic Operations Bureau/Vice/Drug Bureau via Data Analysis Unit SECTION 9: Related Data Page | 120 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Boulder Police Department Marijuana Public Consumption Citations 199 200 151 129 150 72 100 50 79% Increase 17% Increase32% Increase 0 2013201420152016 SOURCE: Boulder Police Department, Records and Information Services NOTE: T HE C ITY OF B OULDER DID NOT HAVE A MUNICIPAL STATUTE SPECIFIC TO PUBLIC CONSUMPTION OF MARIJUANA UNTIL MID-2013. Case Examples Marijuana : After indicting thirteen people involved in illegally distributing around 200 pounds of marijuana District Attorney Dan May stated in a public announcement, homicides in Colorado Springs last year, 2016. Eight of those were directly marijuana. During the public announcement May explained that authorities are overwhelmed having to deal with the crime that is associated with marijuana and claimed that 1 Homicides h: urban area located in El Paso County. Neither the city nor the county permit the sale of recreational marijuana but both allow medical marijuana. Even so, the Colorado Springs Police Department stated 11 of the 59 homicides that occurred in Colorado Springs between 2015 and ear. According to the SECTION 9: Related Data Page | 121 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 2 during a mar Pot Deal Ends in Gunfire when Buyer Realizes they Bought Broccoli: Local Colorado drug dealers, Tercell Davis and Sababu Colbert-Evans, Both parties had already driven off when the buyers realized they had actually purchased broccoli instead of marijuana. The buyers noticed they had been duped and arranged another meeting argument broke out, and Colbert-Evans and Davis fired 11 shots at the fleeing would-be 3 Texas Trio Charged with Murder during Marijuana Robbery: Three individuals from Texas were charged with first-degree murder while attempting to rob David Gaytan in May 2017. The shooting that lead to the death of David Gaytan occurred at a mobile home park in Lightner Creek, Colorado. District Attorney Christian Champagne, in a response to the shooting, stated, which makes the state a target for people with nefarious intent from other states. from other states to commit crimes in our community are going to be dealt with 4 very seriously, and t At Least Eleven Pot-Related Homicides Since Legalization: In response to the recent conviction of Shawn Geerdes, an owner of a shared marijuana grow who murdered his business partner, a local Colorado District Attorney i least eleven pot- state have noted significant violent crime related to marijuana cultivation and n to homicide, he noted that there are additional crimes such as -murder cases in our community also motivated by 5 Triple Homicide at Illegal Marijuana Grow: 24-year-old Garrett Coughlin was charged with six counts of first degree murder after being accused of killing 3 people in Boulder County. by Coughlin on April 13, 2017. aw Coughlin with large amounts of marijuana packaged in a manner consistent with the marijuana owned by the victims, as well as SECTION 9: Related Data Page | 122 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 large amounts of Over 100 plants were found at the 6, 7 murder location. A Troubling Weakness in Colorado Marijuana Enforcement: Former Colorado Marijuana Enforcement Officer, Renee Rayton, was recently indicted due to her involvement in shipping millions of dollars worth of marijuana outside the state. Within weeks after leaving her state employment she was working for a shell company, federal law by shipping marijuana outside of Colorado, Rayton also breached a specific During her time with Harmony & Green, Rayton reportedly bragged about knowing someone at the Colorado Department of Reven regulatory field experience. orcement Division was correct in asking the Colorado Bureau of Investigation to conduct an independent investigation, this example of an Enforcement Officer gone bad highlights the complexities and challenges involved in regulating recreational marijuana. Department 8 County Official Arrested Over Illegal Pot Grow: According to investigators, Ted Archibeque, the elected Eagle County surveyor, and his brother Thomas Archibeque are illegal grow. Local officials and the DEA served a warrant to a property owned by Ted 9 surveyor on administrative suspension. SECTION 9: Related Data Page | 123 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Revenue Colorado's Statewide Budget, Fiscal Year 2017 Marijuana Tax Revenue* (Medical and Recreational) = 0.8% *Revenue from marijuana taxesas a portion of Colorado's total statewide budget SOURCE: Total Revenue from Marijuana Taxes, Calendar Year 2016 Retail Marijuana TaxesMedical Marijuana Taxes 200,000,000 167,157,150 150,000,000 83,750,123 100,000,000 59,420,537 23,986,490 50,000,000 12,462,467 12,462,467 NA NA 0 2.9% Regular10% Special15% ExciseTotal 2016 Taxes SalesSales SOURCE: Department of Revenue, Monthly Marijuana Taxes, Licenses and Fees Transfers and Distribution, 2016 NOTE: F IGURES D O N OT INCLUDE ANY CITY TAXES; THE S TATE DOES NOT ASSESS OR COLLECT THOSE TAXES. SECTION 9: Related Data Page | 124 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Case Example Falling Marijuana Prices Mean Trouble for States that Have Legalized: As more time elapses since marijuana legalization, prices for marijuana are expected to continue to f marijuana prices over time in Colorado perfectly parallels the pattern in Washington after that state legalized: Prices briefly spiked due to initial supply shortages, but then began dropping as the marijuana industry matured and expanded. Wholesale prices in Colorado tumbled 24.5 o to compensate for this d, an increase in heavy cannabis users dropping out of school, and so on. If the state adopts measures to cut soaring consumption, it will by definition lose tax revenue, potentially making the 10 recreational marijuana system unable to pay for its own regulatory SECTION 9: Related Data Page | 125 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Event Planners Views of Denver SOURCE: VISIT DENVER, Impacts of the Downtown Environment on the Tourism Industry and Visitor Perceptions report VISIT DENVER is the marketing organization for the city and it measures, records and reports hundreds of data points, to include safety trends and feedback received from convention and leisure visitors. Based on data collected they came away with three key takeaways: 1. surpassing any other categories. The severity of this issue has increased and as of 2014 nearly 50% of meeting planners negatively commented on homeless, youth, panhandling, safety, cleanliness, and drugs including public marijuana 2. ranks very high on walkability, affordability, facilities, and other interviews with key convention planners conducted by an independent third- 3. ors and valuable convention business as a result of these overall safety (or perception of safety) issues. Unfortunately, word is beginning to spread among meeting planners about the safety challenges Denver is facing. SECTION 9: Related Data Page | 126 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 As the market organization for the city, we fear not being able to brand Denver Comments made by the Colorado Convention Center clients and visitors to Denver: a convention in your city. We are staying at Embassy Suites downtown on th 16, and last night witnessed a group of about 30 teenagers attack a man th walking along 16 street. I am told this is not an unusual occurrence. The homeless situation is very sad, and public streets reek of weed. The Denver police should be more alert to large groups of minors congregating on city streets attacking tourists. My feedback from this meeting will be to never locate here again; I have felt much safer in downtown NYC, Philly, Seattle, a th generation Colorado native. I am downtown for a national convention and within 10 minutes of walking to the Convention Center I was drunks, disheveled people, smelled weed being smoked in the open. It was disgusting and I thought so this is where the current government is taking us. I use \[sic\] to be so proud of Denver and Colorado; today I was heart sick and o colleagues coming from other San Antonio. I would like to share with you why Denver dropped off his list. This client does a lot of business in Denver and was disappointed to see, in his opinion, how things have changed in the city since marijuana was legalized. He says he sees lots meeting we hosted for our industry in Denver in July \[2015\]. It was held with delegates arriving as early as July 11 and continued through July 15. This is a meeting of industry executives and business owners from around the entire country. The meeting was headquartered at the Sheraton downtown. The comments from the President who echoed these comments about a reluctance to return to Denver based on the condition of the City and the abundance of homeless people walking the mall and in and about the downtown area. The SECTION 9: Related Data Page | 127 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 attendees were also less than complementary with Denver and in particular the downtown area. Some of the comments received from attendee in survey after the conference were: o o o t remember th o Street mall on Sunday evening having a beer, I turned my head to look at a television, when I turned back a street person was drinking my beer. I am sure this is not an image Denver wants portrayed around the Homeless How Recreational Weed is attracting People, but Spiking tHomeless Rate: An article written in the summer of 2016 described the journey of a young man from a small town in Texas to the Southern Colorado town of Pueblo. In the first half of a two- part article, Devin Butts describes his journey to Colorado which was made largely due decided that cannabis would be the only indulgence he would keep as he tore himself Devin is not alone in his journey to Colorado; in fact, there are many others that have followed shelters while trying to make a new future. survey conducted by a grad student last year found that between 17 and 20 come to the area in part because of medical marijuana. If anything, said Luehrs and his colleagues, that figure is low. At the nearby Salvation Army Crossroads Shelter, an informal survey of 500 newcomers in the summer of 2014 determined 11 that nearly 30 percent were there because of cannabis. SECTION 9: Related Data Page | 128 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Marijuana Legalization: Pot Brings Poor People to Colorado, bBeing Done To Help Them?: In the second part of a summer 2016 article written to describe the journey of a young man to Colorado, Devin Butts describes his newfound perspective. Devin, along with hundreds of other individuals who relocated to Colorado in pursuit of marijuana-related opportunitie hoping for especially with regards to finding employment. The vice president of communications and public policy for the Colorado Coalition for the Homeless spoke about hourly wage requirements to live in Denver, which is bad news for marijuana migrants looking for work. According to Cathy Alderman, marijuana trimmers usually start at around $10 an hour, and budtenders working in the s to indicate significant challenges for those hoping to move to Colorado in pursuit of greater futures. Relatedly, an unexpected consequence of the legalization of recreational marijuana is the surge in the homeless population in many Colorado cities. Recently, the city of Aurora pledged $4.5 million in cannabis revenue to homeless programs certainly an unforeseen cost. Although this might seem to be a step in the right direction in order to help those in need, it might also signal a trend in government spending and population 12 dependency at least partially brought-on by the legalization of recreational marijuana. A Salvation Army Captain recently spoke with reporters about the growing homeless population. Captain Eric Wilkerson said that the cause is most likely what many Denver citizens suspect, the increase in homelessne experiencing homelessness tell us, anecdotally, that 20 (percent) to 30 percent of people they encounter who are moving to Colorado tell them that they are moving here, in Although the city of Denver has pledged large sums of money to those in need of affordable housing, a local branding and marketing expert expressed her concern that we get ahead of this growing trend as the last thing she wants is for her city to have the 13 Legalized Marijuana Turns Colorado Resort Town into Homeless Magnet: Several people holding cardboard signs can be seen lining the sidewalks and streets of Durango, CO. Durango is a picturesque, upscale community where many businesses SECTION 9: Related Data Page | 129 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 rely on tourism. The city has recently become overrun with transients and panhandlers, many of them people between the ages of 20-30. One resident and business owner small city has also experienced an increase in crime, 14 placing its property crime rate 12 percent higher than the national average. Suicide Data Average Toxicology of Suicides Among Adolescents Ages 10 to 19 Years Old (With Known Toxicology) 2006-20082009-20122013-2015 Pre-CommercializationPost-CommercializationLegalization 3.80% 4.20% Antidepressant 4.70% 0.00% 6.60% Opioid 4.70% 0.00% 1.90% Cocaine 2.30% 3.80% 2.30% Amphetamine 4.70% 12.00% 11.70% Alcohol 8.70% 13.50% 17.40% Marijuana 16.30% 0.00%5.00%10.00%15.00%20.00% Percent SOURCE: Colorado Department of Public Health and Environment (CDPHE), Colorado Violent Death Reporting System SECTION 9: Related Data Page | 130 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Average Toxicology Results by Age Group, 2013-2015 Ages 10 to 19Ages 20+ 38.6% 40% 35% 30% 25% 20.0% 17.4% 16.3% 20% 15.8% 15% 8.7% 6.8% 10% 4.7%4.7% 4.7% 2.8% 2.3% 5% 0% MarijuanaAlcoholAmphetamineCocaineOpiodAntidepressant SOURCE: Colorado Department of Public Health and Environment (CDPHE), Colorado Violent Death Reporting System Marijuana is the only substance where youth, ages 10 to 19, have a higher percentage than adults, ages 20 and older. SECTION 9: Related Data Page | 131 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 THC Potency National Average THC Potency Submitted Cannabis Samples 14.00% 11.99% 12.09% 11.13% 12.00% 12.27% 9.75% 9.58% 10.00% 11.04% t 10.36% 8.02% n 9.93% e c 7.15% r 8.00% e 8.76% P 6.11% 8.14% C 5.01%7.20% 6.00% H 4.60% T 3.96% e g 5.34% a 4.00% r 4.91% e 4.51% v A 2.00% 0.00% 567890123456789012345 999990000000000111111 999990000000000000000 111112222222222222222 SOURCE: Potency Monitoring Program, Quarterly Report Number 135, National Center for Natural Products Research (NCNPR) at the University of Mississippi, under contract with the National Institute on Drug Abuse. 15 The average potency for buds/flower in Colorado is 17.1 percent. SECTION 9: Related Data Page | 132 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 National Average THC Potency Submitted Hash Oil Samples 55.85% 60.00% 53.52% 50.79% 50.00% 49.98% t n e 36.16% 40.00% c r e 31.32% P 28.58% C 35.28% 30.00% H 24.85% T 22.51% e g 18.74% 18.20% a 16.21% r 20.00% e v 13.23% 19.44% A 12.71% 15.54% 15.78% 10.00% 12.82% 6.73% 6.40% 0.00% 567890123456789012345 999990000000000111111 999990000000000000000 111112222222222222222 SOURCE: Potency Monitoring Program, Quarterly Report Number 135, National Center for Natural Products Research (NCNPR) at the University of Mississippi, under contract with the National Institute on Drug Abuse. 15 The average potency for concentrates in Colorado is 62.1 percent. SECTION 9: Related Data Page | 133 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Alcohol Consumption It has been suggested that legalizing marijuana would reduce alcohol consumption. Thus far that theory is not supported by the data. Colorado Average Consumption of Alcohol 143,777,836 144,000,000 142,000,000 136,364,158 140,000,000 138,000,000 136,000,000 134,000,000 132,000,000 5% Increase 130,000,000 Pre-LegalizationPost-Legalization 2010-20122013-2016 SOURCE: Colorado Department of Revenue, Colorado Liquor Excise Tax Colorado Consumption of Alcohol 147,488,339 Legalization 148,000,000 146,000,000 143,468,372 142,970,403 144,000,000 141,184,231 142,000,000 136,778,438 140,000,000 136,489,856 138,000,000 135,824,179 136,000,000 134,000,000 132,000,000 130,000,000 2010201120122013201420152016 SOURCE: Colorado Department of Revenue, Colorado Liquor Excise Tax SECTION 9: Related Data Page | 134 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 16 Medical Marijuana Registry Medical Marijuana Registry Identification Cards December 31, 2009 41,039 December 31, 2010 116,198 December 31, 2011 82,089 December 31, 2012 108,526 December 31, 2013 110,979 December 31, 2014 115,467 December 31, 2015 107,534 December 31, 2016 94,577 Profile of Colorado Medical Marijuana Cardholders: Age of cardholder o 63 percent male, with an average age of 43 years o 0.3 percent between the ages of 0 and 17 o 46 percent between the ages of 18 and 40 21 percent between the ages of 21 and 30 Reporting medical condition of cardholder o 93 percent report severe pain as the medical condition o 6 percent collectively report cancer, glaucoma and HIV/AIDS o 3 percent report seizures SECTION 9: Related Data Page | 135 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Percent of Medical Marijuana Patients Based on Reporting Conditions, 2016 93% 100% 90% 80% 70% 60% 50% 40% 25% 30% 13% 20% 4% 3% 10% 1%1%1% 0% CachexiaCancerGlaucomaHIV /MuscleSeizuresSeverSevere AIDSSpasmsNauseaPain SOURCE: Colorado Department of Public Health and Environment, Medical Marijuana Statistics NOTE: T OTAL DOES NOT EQUAL 100 PERCENT AS SOME PATIENTS REPORT USING MEDICAL MARIJUANA FOR MORE THAN ONE DEBILITATING MEDICAL CONDITION. SECTION 9: Related Data Page | 136 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 st 17 Colorado Licensed Marijuana Businesses as of August 1, 2017 Medical Marijuana: 759 marijuana cultivation facilities 507 medical marijuana centers (dispensaries) 255 infused products (edibles) businesses 14 testing facilities Recreational Marijuana: 701 marijuana cultivation facilities 498 marijuana retail stores 273 infused product (edibles) businesses 13 testing facilities Business Comparisons, June 2017 Figures for business comparisons were all acquired by June of 2017 for comparable data. Colorado Business Comparisons, June 2017 513 600 491 500 392 400 208 300 200 100 0 McDonaldsStarbucksRetail MarijuanaMedical StoresMarijuana Dispensaries SOURCE: Colorado Department of Revenue; S tarbucks Coffee Company, Corporate Office Headquarters; McDonalds Corporation, Corporate Office Headquarters SECTION 9: Related Data Page | 137 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 18 Demand and Market Size The Colorado Department of Revenue published a report in July 2014 called A follow-up to this report showed data for 2015. Some of the information included: Demand In 2015, the established demand for marijuana by Colorado residents 21 years and older is 134.7 metric tons (296,962.67 pounds) of marijuana. In 2015, the estimated demand for marijuana by out-of-state visitors 21 years and older is 14.0 metric tons (30,864.7 pounds). Market Size There are an estimated 569,000 Colorado adult regular marijuana users (at least once per month). Heavy users who consume marijuana nearly daily make up less than 25 percent of the user population but account for 76.4 percent of the demand for marijuana. SECTION 9: Related Data Page | 138 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 19, 20 Marijuana Enforcement Division Reported Sales of Marijuana in Colorado In 2015: 144,537 pounds of medical marijuana flower 106,932 pounds of recreational marijuana flower 2,261,875 units of medical edible products 5,280,297 units of recreational edible products In 2016: 159,998 pounds of medical marijuana flower 175,642 pounds of recreational marijuana flower 2,117,838 units of medical edible products 7,250,936 units of recreational edible products A single ounce of marijuana, depending on the solvent type and production 15 method, can produce between 347 and 413 edibles of 10 mg \[THC\] strength. 2017 Price of Marijuana Marijuana prices as of July 2017 are based off a compilation of medical and recreational prices from local dispensaries and averaged: Area Gram Ounce State Average $11.00 $191.00 Denver $11.00 $159.00 Boulder $13.00 $213.00 Fort Collins $11.00 $235.00 Colorado Springs* $8.00 $157.00 *Colorado Springs does not allow selling of recreational marijuana within city limits. SOURCE: Marijuanarates.com, Accessed August 29, 2017 SECTION 9: Related Data Page | 139 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Local Response to Medical and Recreational Marijuana in Colorado 21, 22 Recreational Marijuana Business and Local Jurisdiction Response: * SOURCE: Colorado Counties, Inc.; as of August 4th, 2017 *N OTE: T HIS MAP SHOWS THE REGULATORY STATUSES OF UNINCORPORATED AREAS WITHIN EACH COUNTY. M UNICIPALITIES WITHIN EACH COUNTY SET POLICY WITHIN THEIR BOUNDARIES. 64 counties* o 61 percent have prohibited or have a moratorium (39) o 39 percent have allowed (25) * Broomfield and Denver are both a city and county but included only once in county data. 243 municipalities (cities and incorporated areas) have taken action on the issue o 72 percent have prohibited (167) or have a moratorium (8) o 28 percent have allowed (68) SECTION 9: Related Data Page | 140 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 21, 22 Medical Marijuana Business and Local Jurisdiction Response: SOURCE: Colorado Counties, Inc.; as of July 31, 2017 *N OTE: T HIS MAP SHOWS THE REGULATORY STATUSES OF UNINCORPORATED AREAS WITHIN EACH COUNTY. M UNICIPALITIES WITHIN EACH COUNTY SET POLICY WITHIN THEIR BOUNDARIES. 64 counties* o 59 percent have prohibited or have a ban on new businesses (38) o 41 percent have allowed (26) * Broomfield and Denver are both a city and county but included only once in county data. 177 municipalities have taken action on the issue o 65 percent have prohibited (115) o 35 percent have allowed (62) SECTION 9: Related Data Page | 141 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Local Jurisdictions Reporting Marijuana Licensing Status 20 as of December 31, 2016 Medical and Retail Marijuana Banned 212 Medical Marijuana Licenses Only 18 Retail Marijuana Licenses Only 11 Medical and Retail Marijuana Licenses 79 2016 Local Jurisdiction Licensing Status 25% Medical and Retail Banned 3% Medical Only 66% 6% Retail Only Medical and Retail Allowed SOURCE: Marijuana Enforcement Division, 2016 Annual Update For Further Related Data See Page 158 SECTION 9: Related Data Page | 142 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Sources: 1 July 25, 2017, <http://www.kktv.com/content/news/Black-market-marijuana-bust-leaves-bruises-on- Colorados-marijuana-industry-436622893.html>, accessed July 31, 2017. 2 th Denver Channel, March 15, 2017, <http://www.thedenverchannel.com/news/local-news/colorado-springs-police-18- percent-of-homicides-since-2015-have-marijuana-nexus-no-state-data>, accessed August th 29, 2017. 3 Kieran Nicholson, l Denver Post, <http://www.denverpost.com/2017/07/25/aurora-marijuana-deal-broccoli-town-center- th gunfire-sentenced/>, accessed September 12, 2017. 4 Shane -degree murder in Lightner Creek Durango Herald, <https://durangoherald.com/articles/164814-texas-trio- th charged-with-first-degree-murder-in-lightner-creek-shooting>, accessed September 12, 2017. 5 George Brauch-Related Homicides Since Legalization, DA Westword, < http://www.westword.com/news/marijuana-related-homicides-in- th colorado-since-legalization-9345285>, accessed September 12, 2017. 6 Canyon Triple Homicide To Appear in Daily Camera, <http://www.dailycamera.com/boulder-county- news/ci_30994865/suspect-coal-creek-canyon-triple-homicide-appear- court?source=pkg>, accessed September 11, 2017. 7 hlin Charged With 6 Murder Counts in Coal Creek Daily Camera, <http://www.dailycamera.com/boulder-county- news/ci_30996366/suspect-coal-creek-canyon-triple-homicide-charged-six?source=pkg>, accessed September 11, 2017. 8 The Cannabist, SECTION 9: Related Data Page | 143 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 <http://www.thecannabist.co/2017/06/16/colorado-marijuana-enforcement-indictment-wakeup- call/82104/>, accessed September 21, 2017. 9 Jesse Paul, onnection with illegal marijuana g The Denver Post, December 8, 2016, <http://www.denverpost.com/2016/12/08/eagle-county-official-brother-arrested-illegal- marijuana-grow/>, accessed September 22, 2017. 10 th The Washington Post, January 18, 2017, <http://www.thecannabist.co/2017/01/18/marijuana-price-drops-state-revenue/71657/>, rd accessed August 3, 2017. 11 International Business Times, June 20, 2016, <http://www.ibtimes.com/marijuana-legalization- colorado-how-recreational-weed-attracting-people-spiking-2374204>, accessed October 9, 2016. 12 International Business Times, June 21, 2016, <http://www.ibtimes.com/marijuana-legalization-pot-brings-poor-people- colorado-whats-being-done-help-them-2378769>, accessed October 9, 2016. 13 less population, Fox31 Denver, July 7, 2016, <http://kdvr.com/2016/07/07/salvation-army- denver-on-breaking-point-with-homeless-population/>, accessed October 9, 2016. 14 meless FoxNews.com, May 17, 2017, <http://www.foxnews.com/us/2017/05/17/legalized-marijuana-turns-colorado-resort- town-into-homeless-magnet.html>, accessed May 17, 2017. 15 th August 10 <https://www.colorado.gov/pacific/sites/default/files/MED%20Equivalency_Final%2008 th 102015.pdf>, accessed May 12, 2017. 16 st Registry Program Update (as of December 31 SECTION 9: Related Data Page | 144 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 <https://www.colorado.gov/pacific/sites/default/files/CHED_MMR_Report_December_ 2016.pdf> accessed May 12th, 2017. 17 Colorado DLicensees Marijuana Enforcement Division st (As of August 1- marijuana-enforcement-division>, accessed August 31, 2017. 18 ct of Marijuana Legalization in 19 Marijuana Enforcement Division Department of Revenue, September 26, 2016. 20 Department of Revenue, August 2, 2017. 21 , <http://www.cml.org/rmj-action-visual/, accessed 8/29/2017>. 22 Colorado Counties Inc., <ccionline.org>, August 28, 2017. SECTION 9: Related Data Page | 145 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 THIS PAGE INTENTIONALLY LEFT BLANK SECTION 9: Related Data Page | 146 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 SECTION 10: Reference Materials Reports and Articles Impaired Driving Higher Levels of THC 5ng/mL. However, according to the Denver Post levels only occasionally topped CO attributes the rise in THC levels of drivers to the rise in THC potency in marijuana 1 Cannabis-Impaired Driving is a Public Health and Safety Concern: According to a 2015 study which aimed to examine some of the issues surrounding cannabis impaired - tetrahydrocannabinol (THC) in blood or oral fluid increased to 12.6%, a 48% increase f marijuana in multiple states, this 2 is likely a national trend we will see continue in the years to come. Controlled Cannabis Vaporizer Administration with and without Alcohol: Researchers behind a 2015 study examined the vaporization of cannabis both with and without blood alcohol present in the systems of thirty-two regular cannabis smokers. As noted in the Clinical Chemistry article, smoking is the most common administration route of cannabis but the use of vaporization is increasing rapidly. The conclusions section of the study stated that the significantly higher blood THC concentration values from cannabis-r underscore the complexities and issues that need to be closely examined, especially when 3 considering drugged driving legislation. SECTION 10: Reference Materials Page | 147 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Correlates of Marijuana Drugged Driving and Openness to Driving While High: A 2015 study funded and independently conducted by RTI International, a nonprofit research and technical services organization, examined 865 Colorado and Washington residents who self-reported using marijuana in the past 30 days. Two behaviors were looked at among the group of study participants; any instances of driving while high in the last year, and driving within 1 hour of using marijuana 5 or more times in the past month. -year driving while under the inf of driving within 1 hour of using marijuana at least 5 times in the past month was marijuana DUI are likely to be more successful by targeting safety perceptions related 4 to marijuana A 2-Year Study of THC Concentrations in Drivers: A recent study aimed to examine police and Drug Recognition Expert (DRE) evaluations with regards to driving under the influence of marijuana. Researchers hoped to determine whether or not a correlation exists between whole-blood THC concentrations and field sobriety test performance. dy did not find a correlation between performance on field sobriety tests and the concentration of THC tested in whole-blood permissible driving limits. Much more research is needed in order to come up with appropriate marijuana driving laws/legislation throughout the country. Furthermore, the researchers concluded that, - impaired drivers are similar to those seen in alcohol- observed driving behaviors of study participants included speeding, the inability to 5 maintain lane position, and running red lights or stop signs. 57 Percent of Marijuana Users in Colorado Admit Driving within 2 Hours: A survey conducted by the Colorado Department of Transportation discovered that 57 percent of people who reported using marijuana drove within two hours after consumption. The survey also indicated that, on average, those participants who reported consuming marijuana and then driving within 2 hours did so on 11.7 of 30 days. By comparison, 38 percent of respondents who drank alcoholic beverages reported driving within 2 hours 6 after consumption and only reported doing so on 2.8 of 30 days. DRE Examination Characteristics of Cannabis Impairment: The frequently-debated 5ng/mL blood THC per se cutoff has been the source of much controversy since SECTION 10: Reference Materials Page | 148 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 legalized marijuana has hit the scene. In 2016, a study of Drug Recognition Expert mbined observations on psychophysical and eye exams produced the best cannabis- significant differences were detected between cases with blood THC >5ng/mL versus <5ng/m-to-nose test was seen as the best indicator of cannabis impairment, with the values of sensitivity, specificity, predictive value and 7 efficiency being considered. Smoked Cannabis Psychomotor and Neurocognitive Effects in Occasional and Frequent Smokers: A group of researchers interested in examining the severity of psychomotor performance, cognition, and driving ability differences among frequent and occasional users of cannabis found substantial differences among the frequent users and the occasional users. During th 4x/week) and 11 occasional (less than 2x/week) cannabis smokers entered a secure Cognitive and psychomotor performance was measured in a variety of ways at certain intervals of time both prior to and after the drug use. frequent cannabis smokers in psychomotor, subjective and physiological effects following cannabis smoking, with weaker effects in frequent smokers suggesting tolerance development. Impairment domains included those that play a key role in 8 Time Profile of Serum THC Levels in Occasional and Chronic Marijuana Users after Acute Drug Use: Although it is commonly accepted that cannabis consumption has the ability to influence cognitive and psychomotor functions, the rules on how to assess the ability to drive while under the influence of d delta-9- tetrahydrocannabinol (THC) impairs cognition, psychomotor behavior and driving performance in a dose- the time profile related to cannabis consumption and the related physiologic affects (through observation of human volunteers), it is apparent that there is 9 d in an Effect of Blood Collection Time: Drug testing is a highly scrutinized topic when it comes to marijuana use and the operation of motor vehicles. This topic has been made even more controversial as several states have legalized marijuana for medical and/or SECTION 10: Reference Materials Page | 149 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 recreational use. Therefore, a group of researchers examined the impact of blood collection time on toxicological evaluation for THC. Researchers found that blood THC concentrations at the time of driving cannot be 10 reliably determined due to individual variances. Drivers Killed in Crashes More Likely to be on Drugs than Alcohol: A recent percent of drivers in fatal accidents compared to 37 percent with alcohol above the legal limit. Additionally, 36 percent of the drivers tested had marijuana present in their system at the time of the accident. In general, traffic fatalities are rising and can be attributed to factors such as improved economy, more distracted drivers, and more 11 drugged drivers. Drug-impaired Driving: In this report, Dr. James Hedlund, under contract with the knowledge on drug-impaired driving, including what little is known about the costs and effectiveness of these actions, and identifies actions states can take to reduce drug- and Reporting System (FARS) and various roadside surveys conducted in multiple -impaired driving is more complex than alcohol--injured drivers with known test results tested positive for drugs or marijuana in 2015, more than tested - impaired driving and drug-impaired driving and made recommendations for states to 12 enact education programs, legislation, and officer training programs. SECTION 10: Reference Materials Page | 150 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Youth Marijuana Use Marijuana Use up among Teens since Legalized in Colorado, Washington: Researchers at the University of California Davis and Columbia University Mailman before and after recreational marijuana was legalized in their state. The study, which used nation-wide data of nearly 254,000 students who participated in the Monitoring the Future survey, showed that legalization of recreational marijuana significantly th graders and 16 th percent in 10 graders in Washington state but not in Colorado. Researchers attribute industry that was established prior to recreational legalization. Youth were exposed to substantial advertising from the medical marijuana industry and therefore Colorado has had lower rates of perceived harmfulness and higher rates of use compared to Washington state and other states. The researchers recommend that states considering legalizing recreational marijuana should also consider investing in substance abuse 13 prevention programs for adolescents. Pot Smoking Common among Pregnant Teens: A recent national survey given to approximately 14,400 pregnant women aged 12-44, found pregnant 12- to 17-year-olds use marijuana as their non- constituted 14% of the surveyed mothers-to-be. Teen pregnancies are already caused by marijuana use. According to Dr. Judy Chang, associate professor of obstetrics, Some thinking and learning abilities, \[and\] kids who find it harder to do more complicated e 14 - Unintentional Pediatric Exposures to Marijuana in Colorado, 2009-2015: Colorado researchers examined the effects of the legalization of marijuana on youth in Colorado by analyzing data regarding pediatric marijuana exposures. Specifically, researchers set out to compare the incidence of pediatric marijuana exposures before and after recreational marijuana legalization. Additionally, this study compared Colorado data with nationwide data. SECTION 10: Reference Materials Page | 151 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 It was found that cases for pediatric marijuana exposure increased significantly and at a higher ra 15 Pediatricians Warn against Use of Pot: A report released in 2017 from the American pot use potential short-term and long-term effects of a mind- Some of these effects may even be permanent. This is particularly true for frequent lo marijuana use at a young age is more likely to lead to addiction than starting in according to gove-17 increasingly think marijuana use is not 16 Adult Marijuana Use Study Finds Increase in Illicit Pot Use, Abuse in States that Allow Medical Marijuana: (JAMA) Psychiatry, researchers noted a significant increase in illegal cannabis use and so-called cannabis- small minority of the population might potentially benefit from medical marijuana use, this study aims to quantify how much non-medical, illicit use is taking place over a multi- Those with cannabis-use disorders are described as having withdrawal symptoms, developing a tolerance for the drug, having cravings for the drug, and suffering impaired functioning in daily activities. The lead author of the study, Dr. Deborah Hasin of the Columbia University associated with marijuana use. SECTION 10: Reference Materials Page | 152 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 The study examined cannabis use and cannabis use disorder from 1991-1992 through 2012-2013 timeframes. In the Washington Times somewhat surprised with rates that increased so sharply in Colorado and California, 17 who most experienced increase in dispensaries in 20 Drug Positivity in U.S. Workforce Rises to Nearly Highest Level in a Decade: percentage of employees in the combined U.S. workforce testing positive for drugs has steadily increased over the last three years to a 10- diagnostic tests offered by Quest Diagnostics include oral, urine and hair follicle drug tests. Speaking to oral fluid testing, which provides a 24-48 hour history, the positivity rate increased 47 percent in the past three years. According to the diagnostics -digit increases in marijuana positivity during this time period. In 2015, there was a 25 percent relative increase in percent) of individuals in the general U.S. workforce with a positive drug test for any substance in 18 2015 showed evidence of marijuana use. Marijuana is Not Safe to Smoke: A study conducted by UC Davis academics found multiple bacterial and fungal pathogens in marijuana that can cause serious infections. The weed tested originated from Northern California dispensaries where the Department of Public Health is working on guidelines for marijuana testing to ensure marijuana is safe. George Thompson III, an associate professor of clinical medicine at to smoke marijuana buds, even f leads the pathogens directly into the lungs where they can cause serious illness and 19 even death. These College Students Lost Access to Legal Pot and Started Getting Better Grades: A recent study ou Due to a new policy change to cannabis cafes, noncitizens were barred from buying recreational marijuana from the cafes. Due to this policy change, an experiment substantial improvement in their grades. Specifically, those banned from cannabis cafes 20 More U.S. Women Report Using Marijuana during Pregnancy, Amid Uncertainty on Potential Harms: About 4 percent of pregnant women ages 18 to 44 reported using SECTION 10: Reference Materials Page | 153 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 marijuana during pregnancy. The study conducted between 2002 and 2014 showed an increase of 62 percent from numbers in 2002 to numbers in 2014. Pregnant women are turning towards marijuana to help alleviate nausea caused during pregnancy even though it is discouraged by the American College of Obstetricians and Gynecologists. Studies show links between prenatal marijuana exposure and impaired functions such as impulse control, visual memory, and attention during school years. Other studies showed smoking marijuana during pregnancy may also lead to restricted fetal growth during pregnancy as well as increased frontal cortical thickness among school-aged 21 children. Pregnant Women Turn to Marijuana, Perhaps Harming Infants: Doctors and dence on the effects of prenatal marijuana use has been limited up to this point, which may contribute to the false perception of safety by some. However, preliminary research indicates that can cross the placenta and reach the fetus potentially harming development. In addition, because THC is stored in fat and can linger there for weeks or months, breast milk can contain THC. Despite evidence being limited, several studies linking maternal marijuana use have conducted in Pittsburgh and Ottawa show that children whose mothers used marijuana s in listening Much of the research that has been done in this area was done when marijuana was far less potent. An epidemiologist with the University of Washington state he time a mother feels high. Both the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists advise expecting mothers against the use of cannabis during pregnancy citing cognitive impairment and academic underachievement as 22 areas of concern. Causal Relationship Identified between Marijuana Use and Numerous Fetal Issues during Pregnancy: Since 2002, there has been a 62% increase in pregnant marijuana in the United States. The amount of studies regarding marijuana use is limited due to SECTION 10: Reference Materials Page | 154 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 relationship between marijuana use and decreased birth weight, increased spontaneous abortion, impaired neurodevelopment, and functional deficits among children and adults who were exposed \[to ma development is effected by marijuana which leads obstetricians and gynecologists to or the effects of marijuana during pregnancy are Tetrahydrocannabinol (THC) is such that it can remain in maternal b marijuana during pregnancy, as little as once per month, results in fetal exposure that 23 Emergency Department and Hospital Marijuana-Related Admissions Marijuana Abuse Linked to Increased Myocardial Infarction (MI) Risk: Cardiology -opening heart attack. The March 2017 article summarized the results of a study led by Dr. Ahmad Tarek adjusted 3.2-fold increased risk of MI in 25- to 29-year-olds with marijuana abuse noted in their medical records, compared with age-matched controls and a 4.56-fold greater risk among the 30- to 34-year- patients with cannabis abuse noted in their medical records, and spanned a five year period (October, 2011 through September, 2016). between cannabis and MI independent of age, hypertension, diabetes, smoking, and further research on this topic. widely prescribed for treatment of nausea, anorexia, neuropathic pain, glaucoma, seizure disorders, and other conditions, the long-term effects of marijuana on the 24 Marijuana Use and Schizophrenia: New Evidence Suggests Link: New research on are prone to schizophrenia more likely to try cannabis, but that cannabis may also common among individuals with psychosis than it is with the general population. This SECTION 10: Reference Materials Page | 155 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 may be particularly troubling a Further research is needed to determine if there is a definitive genetic link between 25 marijuana use and schizophrenia. Colorado Cannabis Legalization and Its Effect on Emergency Care: With the early commercialization of marijuana in Colorado dating back to the year 2000, and recreational marijuana being voted into law in 2012, Colorado provides a unique opportunity to educate physicians on the different considerations related to increased marijuana-related emergency department visits. This document not only summarizes the epidemiologic effect of legalization, but also discusses the effect of legalization on emergency care. Specifically, researchers discuss acute marijuana intoxication, cannabinoid hyperemesis syndrome, and pediatric exposures in an effort to educate healthcare providers everywhere. With Colorado leading the way regarding marijuana legalization, Colorado physicians are leading the way with regards to recognizing and 26 addressing the associated healthcare trends noted in the population. Trends and Correlates of Cannabis-involved Emergency Department Visits 2004 to 2011: This study published in the Journal of Addiction Medicine utilized data obtained from the Drug Abuse Warning Network over the period of 2004 to 2011. Trends in cannabis-involved emergency department visits were examined for both cannabis-only and cannabis-polydrug instances. Cannabis-polydrug instances are those findings of this study suggest that there is a notable increase in the number of emergency department visits for both cannabis-only and cannabis-polydrug users. In particular, this study highlights the increased numbers for youth and non-Hispanic 27 blacks. SECTION 10: Reference Materials Page | 156 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Marijuana-Related Exposure Cannabis Use Causing Alarming Increase in Emergency Hospital Visits and Childhood Poisoning: Dr. Mark S. Gold, a world renowned expert on addiction-related diseases, summarizes a study published in late 2016 that aimed to examine trends and correlates of cannabis-involved emergency department visits in the United States from 2004-r both cannabis-only use (51 to 73 visits per 100,000) and cannabis-polydrug use (63 to 100 per 100,000) in those aged 12 and older. Of note, the largest increase occurred in adolescents aged 12-17, and among persons who identified as non- hospitalization increased with older age users, as compared to adolescent admissions. These data suggest a heavier burden to both the patient and to the health care system as associated with the prevalence of cannabis use, specific cannabis potency and dose (which is increasing over time), the mode of administration, and numerous individual 28 Treatment Cannabinoid Hyperemesis Syndrome: Cannabinoid Hyperemesis Syndrome, a 2011 study published by the National Institutes of Health explores various aspects of this clinical condition including the associated epidemiology, pharmacology, clinical presentation, and treatment options. This condition has grabbed the attention of emergency room physicians across the country as many physicians fail to diagnose the condition. prevalence and its other epidemiological characteristics, natural history, and 29 p Use and Diversion of Medical Marijuana among Adults Admitted to Inpatient Psychiatry: Many states, including Colorado, have legalized the medical use of marijuana, but it is unclear how much medical marijuana is being diverted from those medical marijuana patients. Furthermore, marijuana is linked to anxiety, depressive, psychotic, neurocognitive, and substance use disorders, but it is also unclear how many psychiatric patients use marijuana. In this study, a group of Colorado researchers aimed to determine the prevalence of medical marijuana use and diversion among psychiatric SECTION 10: Reference Materials Page | 157 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 inpatients in Colorado. Over 600 participants responded to an anonymous 15-item much more prevalent among adults hospitalized with a psychiatric emergency than in 30 Related Data Everything You Need to Know about Indoor marijuana grows are estimated to use a total of one percent of all electricity used in the United every computer in every home and apartment in the country In order to power all those light fixtures, as well as dehumidifiers and heating and ventilation systems, indoor grow operations use about eight times the amount of energy per square In addition to the electricity needed to sustain a marijuana grow, the plants require a gallons of water per day per plant over the summer. For reference, it takes about four 31 gallons of water to run an energy- High Time to Assess the Environmental Impacts of Cannabis Cultivation: In an attempt to understand the impact that the cultivation of marijuana has on the environment, impacts due to excessive water and energy demands and local contamination of water, air, and soil with waste products such as organic pollutants and agrochemicals \[fungicides, pesticides, e cultivation in either an indoor or outdoor grow requires a significant amount of the responsibility of Environmental Protection Agency, National Institutes of Health, and Occupation Safety environmental impact will be and how to reduce the footprint. However, when it comes U.Sit\] has made it historically difficult for those agencies to actively fund research in 32 SECTION 10: Reference Materials Page | 158 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Cartels are Growing Marijuana Illegally in California and a War Brewing: of lethal poisons growers use to protect their crops and campsites from pests are annihilating wildlife, polluting pristine public lands, and maybe even turning up in other animals from eating the sugar-rich sprouting plants, from gnawing on irrigation grasp t places the public thinks are pristine, with obscene amounts of chemicals at each one. In addition to toxicants, these illegal grows present another environmental estimated that trespass grows use 50 percent more water because of less efficient irrigation systems and added stressors like pests, pathogens, and drier weather at higher elevations. Worse, some trespass growers leave their irrigation systems running 33 around the clock throughout the year, even when nothing is g Thousands of Marijuana Plants Found on Forest Land in Pueblo County: According to Fox31 Denver, there were more than 7,400 marijuana plants discovered in an illegal grow which included two separate fields. Both of the fields were on U.S. Forest Service land near Rye, Colorado. The July 2017 article stated-largest operation uncovered in Pueblo County to date and the fifth found in fields on or near the San Isabel National Forest in the past five years. The four previous grows are believed to be connected to a Mexican cartel. Detectives are investigating whether Pueblo County Sheriff Kirk Taylor reported, These grows are not indigenous to Colorado and the water and fertilizers required for these grow operations represent a Two of the past incidents within the San Isabel National Forest include an August 2012 operation in which over 9,400 plants were involved, and an October 2015 operation in which 2,400 plants were involved. There are countless other illegal grow operations within U.S. Forest Service land, but limited resources prevent any further 34 action to stop these grows and prevent further environmental impact. SECTION 10: Reference Materials Page | 159 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Marijuana Grows Leaving More Colorado Homes Filled with Mold: It is unclear how many homes throughout Colorado are being used to grow marijuana, but Denver Detective Brian Matos estimated \[Denver\].ple grow marijuana plants indoors they bring moisture into the home which is likely to cause mold problems especially if it is a large grow. In many cases, these grows are illegal and the homeowner is simply using the home for the purpose of growing marijuana without any concern for the damage caused. The damage is often compared to that of meth labs, but environmental lawyer Timothy , contamination from meth is grow contamination and destruction can be seen throughout the home. According to the Denver Post e foundation to tap a power electricity they are using. often associated with punching holes through the walls or ceilings for ventilation. The DEA tells the Denver Post that illegal grows are often -middle-class, high-income and resell the home to unsuspecting buyers. This was the case of David and Christine Lynn who recently purchased a $388,000 home that turned out to be a former grow and 35 are currently suing the previous homeowners. Mid-Year Update, by the Colorado Department of Revenue, Marijuana Enforcement Division: This report includes information on marijuana business licensing status, number of plants cultivated for medical and recreational purposes, volume of marijuana sold within both recreational and medical markets, units of infused edibles and non-edibles sold, mandatory retail testing for edibles, enforcement activity and 36 June 2016. Cannabinoid Dose and Label Accuracy in Edible Medical Cannabis Products: A study including 3 California and Washington cities sought to determine the accuracy of dosage labels on edible medical cannabis products. Nine dispensaries selling baked goods, beverages, and candy or chocolate were selected for the study. Individuals with determine whether the indicated levels of tetrahydrocannabinol (THC) and cannabidiol (CBD) of the edible products were accurate, within 10%. Of the purchased products, which included 47 different brands, 17% were determined to be accurately labeled, 23 percent were under labeled, and 60 percent SECTION 10: Reference Materials Page | 160 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 were over labeled for THC content. Forty-four products (59 percent) were found to have detectable levels of CBD, of which only 13 were labeled to include CBD. None of the 13 labels for CBD were accurate, 4 were under labeled, and 9 were over labeled. Inaccurate labeling of products may lead consumers to get more of an effect than desired or not 37 enough to produce the desired medical benefit. Tracking the Monwhy it Matters: The National Families in Action (NFIA) released a report in the early part of 2017 regarding the financial support behind marijuana related ballot initiatives. The NFIA tracked the majority of the financial support on these initiatives for the past two decades to three private parties worth billions of dollars. The report outlines how much money per initiative is contributed by the three billionaires compared to other sources. Additionally, the report gives reasons for why the financial contributions of three 38 individuals matter for the overall legalization of marijuana in the nation. Seed to Sale Tracking for Commercial Marijuana: This report examines the concept of seed to sale tracking for marijuana plants. Radio Frequency Identification (RFID) tracking is discussed along with some of the positives and negatives of Inventory 39 Tracking Systems. Houston HIDTA Marijuana Legalization Threat Assessment Legalization is NOT a : This document, put together by the Houston Investigative Support Center, intends to provide easy access to salient facts regarding the serious negative consequences of marijuana legalization in the United States. Topics addressed include public health and safety ramifications, as well as 40 economic and social impacts of marijuana legalization. Is the Marijuana Industry Actually Making Money for Alaska? One of the most compelling arguments for marijuana legalization is the amount of tax revenue that marijuana would generate. However, with legalization also comes the need for regulation, which also requires money to maintain. In Alaska, the amount of money generated for the 2017 fiscal year was $1.75 million, but the amount of money budgeted for regulation by The Alcohol and Marijuana Control Office was $1.9 million. The goal is that, eventually, the tax revenue generated from the marijuana industry will fully fund the agency. Until then, however, general fund money has to be used to su Alcohol and Marijuana Control Office that by the year 2020 the agency will be self- 41 supported. SECTION 10: Reference Materials Page | 161 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 Working Paper on Projected Costs of Marijuana Legalization in Rhode Island: This paper was written in an effort to inform Rhode Island legislators about the potential economic impact of marijuana legalization in Rhode Island. The paper indicates that lthough a full cost accounting of marijuana legalization would be impossible at present, enough data exists to make rough-and-ready estimates of certain likely direct and short-nistrative and enforcement costs for regulators, costs from drugged driving, health costs from emergency room visits, potential costs related to homelessness, and costs to employers. Costs reported in this paper are projections based off of figures from states with full 42 marijuana legalization. Monitoring Health Concerns Related to Marijuana in Colorado: This 2016 report was published by the Colorado Department of Public Health and Environment in order to address the changes in marijuana use patterns, provide a systematic literature review, and address possible marijuana related health effects in the state of Colorado. The report covers findings addressed by such surveys as the Behavioral Risk Factor Surveillance Survey (BRFSS), Child Health Survey (CHS), Healthy Kids Colorado Survey (HKCS), and the Pregnancy Risk Assessment Monitoring System (PRAMS). In addition to the survey data, the report covers possible marijuana related health effects in Colorado, specifically looking at data from the Rocky Mountain Poison and Drug 43 Center (RMPDC) and the Colorado Hospital Association (CHA). 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Galli, MD; Ronald Andari Sawaya, MD; and Frank K. Friedenberg, Department of Gastroenterology, Temple University School of Medicine, December 2011, <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3576702/pdf/nihms353647.pdf>, accessed August 2, 2017. 30 Abraham M. Nussbaum, Christian Thurstone, Laurel McGarry, Brendan Walker medical marijuana among adults admitted The American Journal of Drug and Alcohol Abuse, <http://www.tandfonline.com/doi/pdf/10.3109/00952990.2014.949727?needAccess=true& >, accessed August 11, 2017. SECTION 10: Reference Materials Page | 166 The Legalization of Marijuana in Colorado: The Impact Vol. 5/October 2017 31 Clayton Aldern, impact, Grist, April 19, 2016, <http://grist.org/living/everything-you-need-to-know- about-pots-environmental-impact/>, accessed July 31, 2017. 32 Environmental Science and Technology, February 17, 2017, <http://pubs.acs.org/doi/ipdf/10.1021/acs.est.6b06343>, accessed July 31, 2017. 33 Business Insider, April 08, 2017, <https://finance.yahoo.com/news/cartels- growing-marijuana-illegally-california-194700553.html>, accessed August 3, 2017. 34 Fox 31 News/Denver, July 3, 2017, <http://kdvr.com/2017/07/03/thousands-of- marijuana-plants-found-on-forest-land-in-pueblo-county/>, accessed August 16, 2017. 35 The Denver Post, July 31, 2017, < http://www.denverpost.com/2017/07/31/marijuana-leaving- colorado-homes-mold/> accessed September 11, 2017. 36 Division: 2016 Mid Year Report (January 1-June 30, 2016), <https://www.colorado.gov/pacific/sites/default/files/Final%20Mid%20year%202016.pdf >, accessed April 19, 2017. 37 Ryan Vandrey, PhD; Jeffrey C. Raber, PhD; Mark E. Raber; et al, The JAMA Network, June 2015, <http://jamanetwork.com/journals/jama/fullarticle/2338239>, accessed March 13, 2017. 38 And Why It Matters <https://www.dalgarnoinstitute.org.au/images/resources/pdf/cannabis- conundrum/Tracking_Marijuana_Money.pdf>, accessed April 20, 2017. 39 March 2017, <https://hidtanmidotorg.files.wordpress.com/2017/03/seed-to-sale_march- 2017.pdf>, accessed March 2017. 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SECTION 10: Reference Materials Page | 168 Articles Major depressive disorder, suicidal thoughts and behaviours, and cannabis involvement in discordant twins: a retrospective cohort study Arpana Agrawal, Elliot C Nelson, Kathleen K Bucholz, Rebecca Tillman, Richard A Grucza, Dixie J Statham, Pamela AF Madden, Nicholas G Martin, Andrew C Heath, Michael T Lynskey Summary Background Early and frequent cannabis use are associated with an increased likelihood of major depressive disorder Lancet Psychiatry 2017 (MDD) as well as suicidal thoughts and behaviours. We identify associations between aspects of cannabis use, MDD, Published Online July 24, 2017 and suicidal thoughts and behaviours and examine whether such associations persist after accounting for those http://dx.doi.org/10.1016/ predisposing factors, including genetic liability and early family environment, that are shared by identical twins who S2215-0366(17)30280-8 are discordant for cannabis exposure. Any residual association in such identical pairs might be indicative of individual- See Online/Comment http://dx.doi.org/10.1016/ S2215-0366(17)30311-5 Methods We did a logistic regression analysis of cannabis use from retrospective data on same-sex male and female Department of Psychiatry, Washington University School twin pairs drawn from 3 studies that had recruited twins from the Australian Twin Registry, 199293 (sample 1), of Medicine, St Louis, MO, USA 19962000 (sample 2), and 200509 (sample 3). We studied associations between early use and frequent use of (A Agrawal PhD, E C Nelson MD, cannabis and MDD, suicidal ideation (ever and persistent), and suicide plan and attempt in the full sample as well as K K Bucholz PhD, R Tillman MA, in pairs of monozygotic and dizygotic twins that were discordant for each measure of cannabis involvement at a R A Grucza PhD, P A F Madden PhD, A C Heath DPhil); QIMR nicotine use, early dysphoric or anhedonic mood, conduct disorder, and childhood sexual abuse. Interactions between Berghofer Medical Research Institute, Brisbane, QLD, Australia (N G Martin PhD); University of the Sunshine Findings In 13 986 twins (6181 monozygotic and 7805 dizygotic), cannabis use ranged from 1345 (30·4%) of Coast, Sippy Downs, QLD, 4432 peo Australia (D J Statham DPsych); 17·9 years (SD 3·3) in sample 3 to 21·1 years (5·2) in sample 1, and frequent use (100 times) was reported by and National Addictions 214 (15·9%) of 1345 users in sample 1 and 499 (21·9%) of 2275 in sample 3. The prevalence of suicidal ideation Centre, Institute of Psychiatry, Psychology, and Neuroscience, ranged from 1102 (24·9%) of 4432 people in sample 1 to 1644 (26·3%) of 6255 people in sample 2 and 865 (26·2%) Kings College London, London, of 3299 people in sample 3. Prevalence of MDD ranged from 901 (20·3%) people in sample 1 to 1773 (28·3%) in UK (M T Lynskey PhD) sample 2. The monozygotic twin who used cannabis frequently was more likely to report MDD (odds ratio 1·98, Correspondence to: 95% CI 1·113·53) and suicidal ideation (2·47, 1·195·10) compared with their identical twin who had used Dr A Agrawal, Department of cannabis less frequently, even after adjustment for covariates. For early cannabis use, the monozygotic point Psychiatry, Washington University School of Medicine, Saint Louis, MO 63110, USA association with suicidal ideation. arpana@wustl.edu Interpretation The increased likelihood of MDD and suicidal ideation in frequent cannabis users cannot be solely attributed to common predisposing factors. Funding National Institute on Drug Abuse, National Institutes of Health, Australian National Health and Medical Research Council. 6 Introduction noted for suicidal thoughts and behaviours and often 4 Cannabis use has been linked to both major depressive dissipate after covariate correction. 1,2,3 disorder (MDD) and suicidal thoughts and behaviours. One approach to understanding the nature of the Daily cannabis use, especially during adolescence, has association between cannabis use and MDD and 4 been associated with a 6·8 odds of suicide attempt. In a suicidal thoughts and behaviours is to study mono- 30-year longitudinal study, even weekly cannabis use has zygotic twins reared together who are discordant for been linked to onset of suicidal ideation, particularly in cannabis use. Some studies have shown the high men, and the association largely persisted after heritability of cannabis use (h ²=5060%), MDD (h ²=3040%), and suicidal thoughts and behaviours 711 sociodemographic and mental health characteristics and (h ²=4045%). Monozygotic twins typically share all 5 familial risk factors. MDD is partly correlated with their segregating loci and are also highly likely to share suicidal thoughts and behaviours. However, associations between cannabis use and MDD are weaker than those cannabis shows an increased likelihood of MDD or www.thelancet.com/psychiatry Published online July 24, 2017 http://dx.doi.org/10.1016/S2215-0366(17)30280-8 1 Articles Research in context Evidence before this study We searched PubMed (Jan 1, 1990Feb 15, 2017) using the causal nature. search terms cannabis, marijuana, depression, suicide, Added value of this study and twin with no language restrictions. Although In this large retrospective study of cannabis, MDD, and suicidal associations between early and heavy or frequent cannabis use thoughts and behaviours in twins (n=13 986), we found that and suicidal thoughts and behaviours are robust when adjusted even within monozygotic pairs, twins who used cannabis for confounders, associations with major depressive disorder (MDD) are neither as strong nor as independent. Rodent criteria for MDD and to report suicidal ideation than their models support the role of the endocannabinoid system in genetically identical twin who had either never used cannabis mood regulation. Cannabis involvement, MDD, and suicidal or had used it less frequently, even after accounting for thoughts and behaviours are heritable. One previous study covariates. We have also shown that ever using cannabis is not found that cannabis-dependent individuals were more likely to as robustly associated with MDD and suicidal thoughts and report suicidal thoughts and behaviours than their behaviours as early or frequent use. monozygotic and dizygotic twins who were not dependent on Implications of all available evidence in dizygotic pairs. An association was also noted between Given the well documented role of endocannabinoid signalling suicide attempt and discordance in early cannabis use in in mood regulation and the results from our study, a causal role dizygotic as well as monozygotic twins. These results suggested of frequent cannabis use in MDD and suicidal ideation cannot that early and heavy or frequent cannabis use, or use resulting be discounted. Preventing escalation in cannabis use might in abuse and dependence, might be related to MDD via genetic ameliorate a portion of the morbidity associated with these pathways alone whereas associations with suicidal thoughts serious mental illnesses. and behaviours might be attributable to non-genetic, suicidal thoughts and behaviours compared with their and subsequently to MDD and suicidal thoughts and twin who does not use cannabis, this residual association behaviours. 12 factors and causal mechanisms. Although cross-Methods sectional discordant twin data cannot prove causality, Study design and participants the absence of an association in discordant twin pairs Data on same-sex male and female twin pairs were drawn might be viewed as evidence against causal mechanisms. from 3 studies that had recruited twins from the Australian 1314 In one such study, we have shown that, relative to their Twin Registry. Three groups of samples formed the twin, the cannabis-dependent twin was 3·4 times more population for the retrospective analysis reported in this likely to report suicidal ideation and attempts. A study. Sample 1 (n=5846) included monozygotic and dizygotic twins aged 2490 years (born between 1902 attempts when discordance for early cannabis use was and 1964) who had either participated in a previous alcohol 1315 examined. By contrast, increased likelihood of MDD challenge study or at least one twin had participated in a 16 was noted in the cannabis-dependent twin in dizygotic survey done in 1989. They were invited to participate in a but not monozygotic twin pairs that were discordant for short telephone interview in 199293, which asked cannabis dependence, suggesting that common genetic questions on cannabis use, age of onset, frequency 13 of cannabis use, MDD, and suicidal thoughts and 17 In this study, we incorporated data from additional behaviours. As the prevalence of cannabis use was low twin datasets (n=13 986 for current study, vs 6257 for the n 1902 See Online for appendix previous study) and we examine additional aspects of and 1940 (n=1414; appendix p 1), these individuals were cannabis use with suicidal thoughts and behaviours. The excluded from the analyses in this study. Sample 2 goals of the study were to examine whether: a lifetime (n=6255) recruited twins aged 2436 years (born history of cannabis use as well as early-onset use and between 1964 and 1971) who were initially included frequent use were associated with MDD, suicidal through the Australian school systems and mass media ideation, persistent ideation, ideation with a plan, and appeals and were interviewed by telephone from 1996 to 2000. This sample was used in an earlier discordant 13 observed in the full sample of twins persisted when twin twin analysis. Sample 3 (n=3299) included twins pairs discordant for each cannabis measure were aged 2732 years (born 19727 18 examined; and associations within pairs of twins interviewed in 200509. Research outlined in this study persisted after accounting for additional covariates that was approved by the Institutional Review Board at might have contributed to discordance in cannabis use Washington University School of Medicine. 2 www.thelancet.com/psychiatry Published online July 24, 2017 http://dx.doi.org/10.1016/S2215-0366(17)30280-8 Articles Procedures 16 years for analyses of suicidal thoughts and behaviours. Respondents in each of the three twin studies were 1 to account questioned with versions of the Australian Semi-for secular trends. Analysis of the full sample was also 17,19 Structured Assessment for the Genetics of Alcoholism. adjusted for age, sex, twin sample, and zygosity. Within All three interviews included identical assessments of cannabis use and suicidal thoughts and behaviours, and whether pairs were drawn from same-sex male or female similar measures of MDD and all covariates.g, cannabis*sex). For cannabis use, respondents were asked whether A similar interaction term was used to they had ever used cannabis during their lifetime. Those in sample (1 vs 2 vs 3; cannabis*sample) as well as birth who reported lifetime use were asked about the age at year (binned as 194154, 195564, 196571, 197279). many times they had used cannabis during their lifetime. Statistical analysis Early use was coded as cannabis use before the age of All primary analyses were done in SAS (version 9). We 18 years for twin sample 1 and before the age of 17 years used logistic regression to examine the association for samples 2 and 3approximately the bottom quartile between cannabis use and either MDD or suicidal of the population. Those who had used cannabis thoughts and behaviours in the full sample. First, we 100 times or more across their lifetime were designated examined whether each measure of cannabis use was as frequent users. Early and frequent use were examined associated with MDD and each index of suicidal thoughts within the pool of individuals who reported a lifetime and behaviours (unadjusted odds ratio \[OR\]). We re- history of cannabis use as well as in the full sample.examined these associations while accounting for In samples 2 and 3, we used DSM-IV criteria to covariates (adjusted OR). 20 diagnose MDD. We assessed DSM-IIIR criteria for We then examined the adjusted associations that were DSM-IV MDD. In samples 2 and 3, onset of MDD was monozygotic and dizygotic same-sex twins that were conservatively assumed to occur when an individual discordant for each cannabis use measure. We used reported experiencing recurring episodes of dysphoria conditional logistic regression for discordant twin (feeling depressed or down for most of the day for (ie, within pair) analyses. Similar to the analyses in the full 2 weeks or longer) or anhedonia (loss of interest in most sample, we calculated an unadjusted OR for the discordant things for most of the day for 2 weeks or longer). In monozygotic and dizygotic pairs. For each unadjusted sample 1, age at onset of the most severe depressive an 1·0 within episode was used. Across the samples, a subset of the discordant monozygotic pairs, we calculated an participants meeting criteria for MDD reported onset of adjusted OR by accounting for only those covariates dysphoric or anhedonic mood (or of the most severe that were associated with within-pair discordance for the episode, if sample 1) before onset of cannabis use respective cannabis measure. We re-analysed paired (n=791). MDD diagnosis was set to missing in these data using a conditional logistic regression bootstrapping individuals for analysis of MDD only.approach in STATA, version 7. A comparison of the All participants were asked if they had ever thought unadjusted OR from the discordant dizygotic and about taking their own life (suicidal ideation) and monozygotic pairs, in relation to the full sample, provided whether they had ever tried to take their own life (suicide an estimate of the extent to which genetic and attempt), regardless of ideation. Additionally, those who environmental factors contributed to the association. reported ideation were asked if they had experienced ideation for longer than a day (persistent ideation) and causal was derived from an adjusted OR of more than 1·0 whether they had made a plan to take their own life in discordant monozygotic twin pairs. (suicide plan). Individuals reporting suicidal ideation (n=868) or suicide attempt (n=140) before onset of correction, we compared the prevalence of the cannabis use were set to missing for analyses related to corresponding MDD and suicidal thoughts and these outcomes only.behaviours measure in discordant monozygotic pairs To control for factors that potentially preceded or with its prevalence in monozygotic twin pairs that were coincided with the onset of cannabis use and might have concordant for cannabis use. been associated with it, we assigned the following factors as covariates: early alcohol use (age <17 years in sample 1; Role of the funding source age <15 years in samples 2 and 3); early tobacco smoking The research was funded by the National Institute on (age <17 years in sample 1; age <13 years in samples 2 Drug Abuse (NIDA) with additional support for aspects of and 3); conduct disorder; childhood sexual abuse (which data collection and personnel support from the National was coded by use of a single common item on whether Institutes of Health (NIH) and the Australian National the respondent had been forced into sexual activity before Health and Medical Research Council (NHMRC). The age 18 years); and dysphoria or anhedonia before age funders had no role in study design, data collection, data www.thelancet.com/psychiatry Published online July 24, 2017 http://dx.doi.org/10.1016/S2215-0366(17)30280-8 3 Articles Sample 1 (n=4432)Sample 2 (n=6255)Sample 3 (n=3299)Total (13 986) Birth years194164*196471197279194179 Year interviewed1992931996200020050919922009 Sex Male1615 (36·4%)2801 (44·8%)1157 (35·1%)5573 (39·8%) Female2817 (63·5%)3454 (55·2%)2142 (64·9%)8413 (60·2%) Mean age38·4 (6·2)29·9 (2·5)31·8 (2·5)33·1 (5·5) Monozygotic twins2089 (47·1%)2636 (42·1%)1456 (44·1%)6181 (44·2%) Opposite sex twins1067 (24·1%)1543 (24·7%)741 (22·5%)3351 (24·0%) Cannabis use Ever used cannabis1345 (30·4%, 29·031·7)3741 (59·8%, 58·661·0)2275 (69·0%, 67·470·5)7361 (52·6%, 51·853·5) Early use286 (21·3%, 19·123·5)863 (23·1%, 21·724·4)857 (37·7%, 35·739·7) 2006 (27·3%, 26·228·3) 214 (15·9%, 14·017·9) 1045 (27·9%, 26·529·4) 499 (21·9%, 20·323·6) 1758 (24·1%, 23·125·1) Mean age at onset21·1 (5·2)18·9 (3·3)17·9 (3·3)19·0 (3·9) Mean lifetime frequency of use92·4 (239·5)185·3 (341·3)138·3 (300·3)154·2 (314·7) Major depressive disorder Major depressive disorder prevalence901 (20·3%, 19·121·5)1773 (28·3%, 27·129·5)814 (24·7%, 23·226·1)3488 (24·9%, 24·325·7) Mean age at onset¶31·0 (7·8)22·3 (5·5)22·8 (5·9)24·8 (7·4) Suicidal thoughts and behaviours Suicidal ideation1102 (24·9%, 23·626·1)1644 (26·3%, 25·227·4)865 (26·2%, 24·727·7)3611 (25·8%, 25·126·5) Mean age at onset24·5 (8·8)20·2 (5·6)20·1 (6·0)21·5 (7·1) Suicidal ideation (>1 day)402 (9·1%, 8·29·9)577 (9·2%, 8·59·9)331 (10·0%, 9·011·1)1310 (9·4%, 8·99·9) Suicidal ideation with plan293 (6·6%, 5·97·3)451 (7·2%, 6·67·8)222 (6·7%, 5·97·6)966 (6·9%, 6·57·3) Suicide attempt136 (3·1%, 2·63·6)260 (4·2%, 3·74·7)148 (4·5%, 3·85·2)544 (3·9%, 3·64·2) Mean age at onset24·5 (9·2)19·4 (5·1)19·8 (5·9)20·8 (6·9) Data are n (%), mean (SD), or n (%, 95% CI). *Participants born 190240 (n=1414) were excluded from analyses because the prevalence of cannabis use was <2% (appendix p 1). have ever used cannabis. ¶ Prevalence of major depressive disorder and suicidal thoughts and behaviours is presented without accounting for temporal orderings (ie, cannabis before outcomes or outcomes before cannabis). For the analyses of major depressive disorder, suicidal ideation, and suicide attempt, we excluded people who had onset of outcomes before onset of cannabis use (791 for major depressive disorder, 868 for suicidal ideation, and 140 for suicide attempt). Characteristics of 13 986 male and female twins from three Australian samples analysis and interpretation, or writing of the study. AA ordering) was lower in sample 1 (1102 \[24·9%\] of 4432) and RT had full access to all data. AA submitted the study than in sample 2 (1644 \[26·3%\] of 6255) and sample 3 for publication.(865 \[26.2%\] of 3299); sample 1 had the lowest prevalence of MDD (901 \[20·3%\] of 4432) and sample 2 had the Results highest (1773 \[28·3%\] of 6255). Similar to cannabis, the After exclusions for missing data in all three sample sets, age at onset of both suicidal ideation and suicide attempt 13 986 twin individuals (6181 monozygotic and 7805 di-was higher in sample 1 (24·5 years) than in zygotic, including opposite-sex) from Australian datasets samples 2 (20·2 years) and sample 3 (20·1 years). acquired between 1992 and 2009 were available for MDD and suicidal ideation (r=0·55) as well as suicide analysis for cannabis use and MDD or suicidal thoughts attempt (r=0·52) were moderately correlated. Nearly all and behaviours. Monozygotic and same-sex dizygotic twin individuals (541 \[99·5%\] of 544) who reported suicide pairs were selected from this sample. Cannabis use was attempt also reported ideation. higher in samples 2 (3741 \[59·8%\] of 6255) and 3 (2275 After temporal ordering, cannabis use was associated \[69·0%\] of 3299) than in sample 1 (1345 \[30·4%\] of 4432; with MDD and suicidal thoughts and behaviours; table 1). Mean age at onset of cannabis use was higher in sample 1 (21·1 years) but similar in sample 2 (18·9 years) after accounting for covariates (table 2, appendix pp 23). and sample 3 (17·9 years; appendix pp 1112). Within Thus, we did not examine cannabis use in discordant cannabis users, early and frequent use were correlated twin models. On the other hand, both early and frequent (r=0·46; appendix p 13), with 44% of early users also cannabis use were robustly associated with MDD and all reporting frequent use of cannabis and 49% of frequent aspects of suicidal thoughts and behaviours (adjusted users also reporting use from a young age. The prevalence ORs ranging from 1·28 to 2·38), even after adjustment of suicidal thoughts and behaviours (without temporal 4 www.thelancet.com/psychiatry Published online July 24, 2017 http://dx.doi.org/10.1016/S2215-0366(17)30280-8 Articles even when lifetime never users of cannabis were excluded Unadjusted OR Adjusted OR* from the analysis; for instance, those who reported using (95% CI)(95% CI) 0 times were twice as likely to report suicidal Cannabis ever use ideation and suicide attempt than those who reported Major depressive disorder1·15 (1·061·25)1·02 (0·931·12) lifetime cannabis use, but less frequently. Overall, these Suicidal ideation1·26 (1·161·37)1·08 (0·981·19) analyses suggest that early and frequent cannabis use are Suicidal ideation >1 day1·35 (1·191·54)1·19 (1·021·38) associated with MDD and suicidal thoughts and Suicide plan1·34 (1·151·56)1·11 (0·931·33) behaviours, even after accounting for key confounders. Suicide attempt1·76 (1·432·16)1·13 (0·881·44) Within-pair associations between early cannabis use, Early cannabis use MDD, and suicidal thoughts and behaviours, in analyses Full sample (n=13 986) Major depressive disorder1·52 (1·361·69)1·28 (1·131·45) dizygotic twins (OR 2·236·50), but not monozygotic Suicidal ideation2·03 (1·822·26)1·57 (1·381·78) twins (OR 1·172·00; table 3). This pattern of results is Suicidal ideation >1 day2·08 (1·782·43)1·55 (1·291·87) Suicide plan2·39 (2·012·84)1·77 (1·442·18) the association. In some instances (eg, suicidal ideation), Suicide attempt3·63 (2·944·47)2·04 (1·582·64) the dizygotic and monozygotic OR had over lapping Subsample of ever users (n=7361) Major depressive disorder1·50 (1·331·70)1·33 (1·161·53) monozygotic pairs, possibly because of marginally fewer Suicidal ideation2·03 (1·792·29)1·68 (1·461·92) discordant pairs. Suicidal ideation >1 day2·01 (1·682·40)1·63 (1·332·00) Associations between frequent cannabis use and MDD, Suicide plan2·44 (2·002·99)2·04 (1·622·57) Suicide attempt3·52 (2·744·51)2·38 (1·783·17) within both dizygotic and monozygotic pairs and with Full sample (n=13 986) attempt (p=0·07) and more conservative bootstrapped Major depressive disorder1·74 (1·551·95)1·53 (1·351·73) Suicidal ideation2·47 (2·202·76)1·96 (1·732·23) estimates (appendix p 4). For instance, compared with Suicidal ideation >1 day2·27 (1·932·66)1·69 (1·402·03) their genetically identical twin who did not use cannabis as Suicide plan2·55 (2·133·05)1·81 (1·472·22) frequently, a monozygotic twin who reported using Suicide attempt3·46 (2·784·30)1·95 (1·512·51) cannabis 100 times or more was more likely to meet Subsample of ever users (n=7361) criteria for MDD (OR 1·72), and report suicide ideation Major depressive disorder1·74 (1·541·97)1·60 (1·401·83) (OR 2·71) and persistent ideation (OR 3·14). A monozygotic Suicidal ideation2·52 (2·222·86)2·07 (1·812·38) OR of greater than one suggests that factors other than Suicidal ideation >1 day2·19 (1·822·62)1·68 (1·382·05) those shared by members of identical twin pairs contribute Suicide plan2·57 (2·103·16)1·94 (1·552·42) to the association. The magnitude of ORs within the Suicide attempt3·19 (2·494·10)2·12 (1·612·80) dizygotic and monozygotic pairs were similar to each other and to associations observed in the full sample (table 2). Interactions between the cannabis exposure variable twins, opposite sex dizygotic twins, conduct disorder, depressed mood or and sex, sample, or birth year category were not Associations between aspects of cannabis use and suicidal was associated with conduct disorder (appendix p 5). thoughts and behaviours in male and female twins from the Australian However, even after accounting for conduct disorder, Twin Registry twins who frequently used cannabis were at 2·352·47 odds of reporting suicidal ideation when compared with their genetically identical twin who did not use cannabis had used it frequently (concordant unexposed), and so frequently or who had never used it at all (table 4; discordant pairs. The prevalence of MDD and suicidal appendix pp 67). For MDD, the association in the subset ideation in concordant exposed twins was greater than in of ever users was robust to covariate adjustment, with concordant unexposed twins (table 5), suggesting a frequent users remaining at 1·98 odds of MDD when compared with their identical twin who used cannabis ideation. Consistent with the discordant twin analyses, less frequently. These results indicated that individual-the exposed twin from discordant pairs was more likely to report suicidal ideation and MDD than their identical the association between frequent cannabis use and MDD but unexposed twin (table 5). Importantly, although there and suicidal ideation (but not persistent ideation). We compared the prevalence of MDD and suicidal individual twins report of suicidal ideation, the rate of ideation across twins drawn from pairs where both had MDD was slightly higher in unexposed twins from used cannabis frequently (concordant exposed), neither discordant than concordant pairs. www.thelancet.com/psychiatry Published online July 24, 2017 http://dx.doi.org/10.1016/S2215-0366(17)30280-8 5 Articles Dizygotic twinsMonozygotic twins Number OR (95% CI)p valueNumber OR (95% CI)p value ²² of pairsof pairs Discordant for early cannabis use (twin is never or later-onset user) Major depressive disorder2931·82* (1·222·70)8·720·00312601·34* (0·852·12)1·600·2057 Suicidal ideation2712·23* (1·453·44)13·380·00032411·50* (0·912·46)2·560·1093 Suicidal ideation lasting >1 day2714·00 (1·938·30)13·840·00022411·67 (0·823·41)1·960·1618 Suicide plan2712·80 (1·365·76)7·810·00522411·17 (0·542·52)0·150·6952 Suicide attempt3166·50 (2·2718·62)12·150·00052781·90 (0·884·09)2·700·1004 Discordant for early cannabis use in ever users (twin is later-onset user) Major depressive disorder1941·47 (0·922·33)2·620·10581941·55 (0·902·64)2·530·1116 Suicidal ideation1762·24* (1·343·74)9·420·00211781·35* (0·762·41)1·030·3090 Suicidal ideation lasting >1 day1764·00 (1·649·79)9·220·00241781·56 (0·673·59)1·070·3011 Suicide plan1762·13 (0·924·92)3·090·07871781·44 (0·623·38)0·720·3964 Suicide attempt2145·33* (1·5518·30)7·080·00782092·00* (0·755·33)1·920·1657 Major depressive disorder2522·12* (1·333·37)9·910·00161991·72* (1·052·82)4·650·0311 Suicidal ideation2412·63* (1·694·10)18·29<0·00011902·71* (1·475·01)10·200·0014 Suicidal ideation lasting >1 day2413·50* (1·607·68)9·770·00181903·14* (1·347·36)6·960·0083 Suicide plan2411·64 (0·773·47)1·660·19821902·14 (0·875·26)2·770·0959 Suicide attempt2764·40* (1·6711·62)8·940·00282252·29* (0·945·56)3·330·0681 Major depressive disorder1741·70* (1·012·84)4·030·04461561·95* (1·123·39)5·580·0182 Suicidal ideation1652·84* (1·694·79)15·33<0·00011472·91* (1·475·77)9·330·0022 Suicidal ideation lasting >1 day1654·00* (1·5010·66)7·690·00561473·60* (1·349·70)6·420·0113 Suicide plan1651·00 (0·402·52)0·001·00001472·20 (0·766·33)2·140·1438 Suicide attempt1926·50* (1·4728·80)6·070·01371822·40* (0·856·81)2·710·1000 Unadjusted within-pair associations between aspects of cannabis use and suicidal thoughts and behaviours, in discordant monozygotic and dizygotic same-sex twin pairs, by dependent variable associated with 0·73 adjusted odds of ideation Number OR (95% CI)²p value (appendix p 8), whereas the corresponding OR for MDD of pairs was 1· frequent cannabis use as a dichotomous measure had Major depressive disorder1981·68 (1·012·80)4·000·0455 Suicidal ideation1902·35 (1·244·48)6·820·0090 categorical measures of cannabis frequency were associated with MDD and suicidal thoughts and Suicidal ideation lasting >1 day1902·24 (0·895·66)2·890·0889 behaviours (appendix p 9 Major depressive disorder1561·98 (1·113·53)5·300·0213 ten units in their frequency of use. Even within these Suicidal ideation1472·47 (1·195·10)5·940·0148 discordant pairs, the twin who used cannabis more Suicidal ideation lasting >1 day1472·72 (0·947·85)3·420·0643 frequently was more likely to report suicidal ideation and MDD (appendix p 10) than their twin who used it less covariates adjusted for conduct disorder (appendix). See appendix for bootstrapped CI. OR=odds ratio. frequently. Within-pair associations between cannabis use and suicidal thoughts and behaviours in discordant Discussion monozygotic twin pairs In this large retrospective study using data from three samples taken from the Australian Twin Registry, We did post-hoc analyses to identify whether frequent we found that early and frequent cannabis use were cannabis use was associated with MDD and suicidal associated with MDD and suicidal thoughts and thoughts and behaviours that occurred before the onset behaviours, even after controlling for confounders. of cannabis use. When suicidal ideation occurred before When these associations were examined within identical the onset of cannabis use, frequent cannabis use was twin pairs, frequent use remained associated with MDD 6 www.thelancet.com/psychiatry Published online July 24, 2017 http://dx.doi.org/10.1016/S2215-0366(17)30280-8 Articles Concordant twins reporting Discordant twins reporting frequent \[less frequent\] Concordant twins reporting frequent useuseless frequent or never use Number Prevalence (95% CI)Number Prevalence (95% CI)Number Prevalence (95% CI) of pairsof pairsof pairs Twins from all monozygotic pairs Major depressive disorder14232·0% (26·637·5)19932·66% (26·139·2) \[23·62% (17·729·5)*\]220019·7% (18·520·9)* Suicidal ideation13040·0% (34·046·0)19032·11% (25·538·7) \[19·47% (13·825·1)\]210117·2% (16·018·3) Twins from monozygotic pairs reporting lifetime cannabis use Major depressive disorder14232·0% (26·637·5)15633·33% (25·940·7) \[21·80% (15·328·3)*\]59618·0% (15·920·2)* Suicidal ideation13040·0% (34·046·0)14732·65% (25·140·2) \[18·37% (12·124·6)\]52316·7% (14·519·0) *The estimate for less frequent or never users from discordant pairs falls outside the 95% CI for the estimate from concordant pairs. Prevalence of major depressive disorder and suicidal ideation in monozygotic twins from pairs concordant for frequent cannabis use, pairs concordant for less frequent or never use, and discordant pairs where one twin reported frequent cannabis use and the other less frequent or never use and suicidal ideation, suggesting that factors beyond endocannabinoid system and a corresponding increase those shared by identical twins might contribute to the association.(ie, concordant frequent vs concordant monozygotic The similarity in the ORs across dizygotic and twins who were less frequent users or had never used monozygotic twin pairs indicates that genetic factors play cannabis) and within pairs (ie, monozygotic discordant only a modest role in the association between cannabis pairs who either frequently used cannabis or who used involvement and MDD and suicidal thoughts and cannabis less frequently or never used cannabis) in rates behaviours, even though previous studies with samples 2 of suicidal ideation as a function of frequent cannabis 21,22 and 3 suggested moderate genetic correlations. The importance of the present study lies in our ability to ideation, there was little evidence that the presence of an disentangle predisposing factors that are related to genetic liability and early familial environment from suicidal ideation, hinting at a potential direct biological who report frequent cannabis use were more likely to cannabis use might lead to increased exposure to 27 report MDD and suicidal ideation than their identical environmental factors (eg, increased trauma exposure) twin who either did not use cannabis or used it less or outcomes (eg, diminished life opportunities, other 4 frequently. Unadjusted and adjusted ORs from the drug use) that might also increase the likelihood of discordant pair analyses were similar to the full MDD and suicidal ideation. For MDD, the twins who population, suggesting that the associations might be due used cannabis less frequently than their frequent-use twin were at an increased likelihood of reporting MDD These results are broadly consistent with but more than concordant unexposed twins, suggesting that the conservative than our previous discordant twin study that environment related to the twins frequent cannabis use made use of data from sample 2 and reported an might modify liability to MDD. Accordingly, we cannot association between early cannabis use and suicide discount the possibility that an unmeasured individual- attempt as well as between cannabis dependence and g, deviant peers, other traumas) is 13 both suicidal ideation and attempt. However, that study contributing to these associations in monozygotic pairs. found no evidence for a residual association between MDD and early cannabis use or cannabis dependence in cannabis use on the subsequent onset of MDD and discordant monozygotic pairs. We see an identical null suicidal thoughts and behaviours cannot be drawn from these cross-sectional data. Even though we only did increase liability to MDD in these twin pairs, perhaps included individuals with onset of MDD and suicidal because of the larger sample size seen in the study thoughts and behaviours subsequent to onset of reported here.cannabis use, we might not have adequately accounted Several mechanisms might explain these associations. for confounders. However, post-hoc analyses found 2324 Evidence from animal and human studies suggests inconsistent associations when this temporal ordering that the endocannabinoid system might be crucial in was reversed. We have previously noted that cannabis modulation of mood, especially in the context of stress. use is negatively correlated with MDD and suicidal 28 MDD and suicidal ideation were among the adverse thoughts and behaviours that precede it. On the basis of earlier examinations of the gateway theory, these 25,26 receptor (CB1) inverse agonist. Frequent cannabis results support the importance of temporal ordering of 29 use mionsets, and hint at causal pathways. www.thelancet.com/psychiatry Published online July 24, 2017 http://dx.doi.org/10.1016/S2215-0366(17)30280-8 7 Articles One strength of the current study is that suicidal mood regulation. However, interventions aiming to curb ideation and suicide attempt were assessed in all cannabis use should form only one part of the broader individuals, regardless of their MDD status. Although strategies to reduce its mental health correlates. Risk and suicidal thoughts and behaviours are noted to be a feature of MDD, they are also frequently viewed as individual but not their sibling can also exacerbate their distinct psychiatric entities that are related, in equal part, liability to MDD or suicidal thoughts and behaviours, to the internalising aspects of mood disorders as well as to externalising behaviours (eg, subtypes of suicide discordance in cannabis use within twin pairs is of 3032 attempt that relate to impulsive aggression). Possibly, considerable importance. suicidal thoughts and behaviours are an early index of a Contributors AA and MTL conceived the study. AA and RT analysed all data. AA was broader liability to emotion dysregulation, with a subset of ideators who progress to MDD. Comparisons of MDD DJS, ACH, and MTL provided expertise on the analytical model, choice of and suicidal ideation prevalence across less frequent or outcomes, and covariates. PAFM, DJS, NGM, ACH, and MTL developed never users from concordant and discordant pairs also instruments, and collected, processed, and coded all data. Declaration of interests status for suicidal ideation). Therefore, the associations AA and RAG have received NIH funding and compensation for grant reviews for NIH outside the submitted work. All other authors declare no between frequent cannabis use, MDD, and suicidal competing interests. Acknowledgments causative processes. The analyses outlined in this study are supported by funds from the Our study has some limitations. First, our sample is National Institute on Drug Abuse (NIDA) grants R01DA040411 and restricted to Australians, and sample 1 was older and is K02DA032573. Additional support for data collection was via National Institutes of Health grants: AA07728, AA10248, AA13321, AA09022, AA10249, AA11998 (ACH), and DA18267 (MTL). Data collection was also possibility, we excluded the earliest-born members of supported by the National Health and Medical Research Council via sample 1 (born in 190240). To show the generalisability 628911, 951023, and 981351. ACH acknowledges AA017688; of the discordant pair analyses, future studies should NGM acknowledges support from the Australian NHMRC Centre for attempt to validate the model in independent datasets. Research Excellence on Suicide Prevention (CRESP). Funding sources were not involved in any aspect of the current research. Second, we were limited by the available cannabis-related variables in the data and could not test for discordance of References 1 Volkow ND, Compton WM, Weiss SR other indices of cannabis use. Similarly, we were unable marijuana use. N Engl J Med 2014; 371: 879. to look in a more nuanced way at subgroups of individuals 2 Price C, Hemmingsson T, Lewis G, Zammit S, Allebeck P. with suicidal ideation and suicide attempt (eg, severity). 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Arch Gen Psychiatry 2012; 69: 73240. 16 Heath AC, Martin NG25 Sam AH, Salem V, Ghatei MA. Rimonabant: from RIO to ban. patterns and problem drinking: results from the Australian NH & J Obes 2011; 2011: 432607. MRC twin panel follow-up survey. Ann NY Acad Sci 1994; 708: 7285. 26 Topol EJ, Bousser MG, Fox KA, et al. Rimonabant for prevention of 17 Heath AC, Bucholz KK, Madden PA, et al. Genetic and cardiovascular events (CRESCENDO): a randomised, multicentre, environmental contributions to alcohol dependence risk in a placebo-controlled trial. Lancet 2010; 376: 51723. 27 Werner KB, McCutcheon VV, Agrawal A, et al. The association of Psychol Med 1997; 27: 138196. 18 Lynskey MT, Agrawal A, Henders A, Nelson EC, Madden PA, an-American and Martin NG. An Australian twin study of cannabis and other illicit European-American women. Drug Alcohol Depend 2016; 162: 16269. drug use and misuse, and other psychopathology. 28 Agrawal A, Tillman R, Grucza RA, et al. Reciprocal relationships Twin Res Hum Genet 2012; 15: 63 141. between substance use and disorders and suicidal ideation and 19 Bucholz KK, Cadoret RJ, Cloninger RC, et al. A new, semi-structured suicide attempts in the Collaborative Study of the Genetics of psychiatric interview for use in genetic linkage studies. Alcoholism. Jrd 2017; 213: 96104. J Stud Alcohol 1994; 55: 14958. 29 Kandel DB. Does marijuana use cause the use of other drugs? 20 American Psychiatric Association. Diagnostic and Statistical JAMA 2003; 289: 48283. Manual of Mental Disorders, 4th edn. Washington, DC: American 30 Klonsky ED, Qiu er B Psychiatric Association, 1994. suicide attempters from suicide ideators. Curr Opin Psychiatry 2017; 21 Delforterie MJ, Lynskey MT, Huizink AC, et al. The relationship 30: 1520. between cannabis involvement and suicidal thoughts and behaviors. 31 Turecki G. Dissecting the suicide phenotype: the role of Drug Alcohol Depend 2015; 150: 98104. impulsive-aggressive behaviours. 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Arch Gen Psychiatry 2002; 59: 112532. www.thelancet.com/psychiatry Published online July 24, 2017 http://dx.doi.org/10.1016/S2215-0366(17)30280-8 9 JournalofSubstanceAbuseTreatment44(2013)400 406 ContentslistsavailableatSciVerseScienceDirect JournalofSubstanceAbuseTreatment Mortalityfollowingtreatmentforcannabisusedisorders:Predictorsandcauses a,b,ab MikkelArendt,MSc,PhD,PovlMunk-Jørgensen,DMSc,LeoSher,MD, a SigneOlrikWallensteinJensen,MSc a UnitforPsychiatricResearch,AalborgPsychiatricHospital,AarhusUniversityHospital,Mølleparkvej10,9100Aalborg,Denmark b DepartmentofPsychiatry,DivisionofMolecularImagingandNeuropathology,ColumbiaUniversityandNewYorkStatePsychiatricInstitute,NewYork,NY10032,USA articleinfoabstract Articlehistory: Theaimofthestudywastodetermineexcessmortalityassociatedwithcannabisusedisorders.Individuals Received1May2012 enteringtreatmentforcannabisusedisorderswerefollowedbyuseofDanishregistersandstandardized Receievedinrevisedform23September2012 mortalityratios(SMRs)estimated.Predictorsofdifferentcausesofdeathweredetermined.Atotalof6445 Accepted26September2012 individualswereincludedand142deathsrecordedduring26,584person-yearsoffollow-up.Mortalitywas predictedbyage,comorbiduseofopioids,andlifetimeinjectiondruguse.Fordifferentcausesofdeaththe Keywords: SMRswere:accidents:8.2(95%CI6.3 10.5),suicide:5.3(95%CI3.3 7.9),homicide/violence:3.8(95%CI1.5 Cannabis 7.9),andnaturalcauses:2.8(95%CI2.0 3.7).Followingexclusionofthosewithsecondaryuseofopioids, Trafcaccidents cocaine,amphetamine,orinjectiondruguse,SMRsforallcausesofdeathremainedsignicantlyelevated Accidents exceptforhomicide/violence.Thestudyunderlinestheneedtoaddressmortalityriskassociatedwith Suicide Standardizedmortalityratio cannabisusedisorders. Recordlinkage ©2013ElsevierInc.Allrightsreserved. 1.Introduction cohortstudies(Arendt,Munk-Jorgensen,Sher,&Jensen,2011; Wahren,Brandt,&Allebeck,1997).Inapreviousstudywefoundan Cannabisisthemostfrequentlyusedillicitsubstanceintheworldestimateof4.9amongcannabisusersfollowingsubstanceabuse withlifetimeusereportedbyalmosthalfofyoungadults(15 treatment(Arendtetal.,2011).EvenhigherSMRsof7.4and8.0were 34years)intheUnitedStates,Australia,andCanada,and32%inthereportedinaSwedishstudyconcerningtwocohortsofhospitalized EuropeanUnion(EuropeanMonitoringCentreforDrugs,Drugpatients(Wahrenetal.,1997).However,thereasonsforthehighlevel Addiction(EMCDDA)\[EMCDDA\],2011;SubstanceAbuseandMentalofexcessmortalityarenotclear.Twopopulation-basedprospective HealthServicesAdministration(SAMHSA)(SAMHSA),2008).Itisstudieshaveinvestigatedifbaselinecannabisuseisassociatedwith estimatedthat9%ofthosewhousecannabisbecomedependentsubsequentincreasedall-causemortality(Andreasson&Allebeck, (Anthony,Warner,&Kessler,1994).Amongpeopleseekingsub-1990;Sidney,Beck,Tekawa,Quesenberry,&Friedman,1997).Crude stanceabusetreatmentforthersttimeinEurope,theproportioneffectswereobservedbutfollowingadjustmentforresidualcon- ofthosewhoreportedcannabisasthemainproblemincreasedfoundingtheseeffectsdisappeared.However,bothstudiesconcern by40%between2004and2009(EMCDDA,2011).Cannabisisnowrelativelyinfrequentcannabisusers(lifetimeuseonmorethan6 thesecondmostcommonillicitsubstanceofabuseamongcitizensoccasionsinSidneyetal.,1997andmorethan50timesinAndreasson ofEuropeanUnioncountriesseekingsubstanceabusetreatment&Allebeck,1990).Nolongitudinalstudieshaveinvestigatedpre- and23%ofthetotalnumberreceivingtreatmentintheEuropeandictorsofall-causemortalityamongindividualswithheaviercannabis Unionreportcannabisasprimarysubstanceofabuse(EMCDDA,useorsufferingfromcannabisusedisorders. 2011).AsimilardevelopmenthastakenplaceintheUnitedStatesAnumberofstudiesareconcernedwithspeciccausesofdeath wheretreatmentadmissionsforcannabisusedisordersmorethanamongcannabisusers.Cannabishasbeenlinkedwithincreasedriskof doubledbetween1993and2005(Budney,Roffman,Stephens,&roadaccidentsandotheraccidents(Calabria,Degenhardt,Hall,& Walker,2007).Lynskey,2010;Darke&Duou,2008;Eksborg&Rajs,2008;Gerberich Inspiteofthesefacts,littleisknownaboutmortalityamongetal.,2003;Laumon,Gadegbeku,Martin,&Biecheler,2005; individualswithcannabisusedisorders.StandardizedmortalityratiosMacdonaldetal.,2003)andisoftendetectedinhomicidevictims (SMRs)associatedwithheavycannabisusehavebeenreportedintwo(Darke&Duou,2008;Macdonaldetal.,2003).Thesubstancehas alsobeenassociatedwithaffectivedisordersaswellassuicide attempts,suicidalideation,andcompletedsuicide(Beautrais,Joyce,& Mulder,1999;Chabrol,Chauchard,&Girabet,2008;Huas,Hassler,& Choquet,2008;Lynskeyetal.,2004;Price,Hemmingsson,Lewis, Correspondingauthor.Tel.:+4572137227;fax:+4572137235. E-mailaddress:mikkaren@rm.dk(M.Arendt).Zammit,&Allebeck,2009).Whiletheriskofdeathfromoverdoseis 0740-5472/$ seefrontmatter©2013ElsevierInc.Allrightsreserved. http://dx.doi.org/10.1016/j.jsat.2012.09.007 M.Arendtetal./JournalofSubstanceAbuseTreatment44(2013)400406 401 generallyconsideredverylow(Kalant,2004),studieshavealsoLarsen,2011).Foreachregistration,itdistinguishesbetweenoverall suggestedthatcannabiscouldleadtocardiovascularfatality(Bachs&causeofdeathandspeciccausesofdeath.Overallcauseofdeathis Morland,2001)ornon-cardiovascularmortalityfollowingmyocardialrecordedinvecategories:naturalcause,accident,suicide,homicide/ infarction(Mukamal,Maclure,Muller,&Mittleman,2008).Finally,violence,andother.Accident,suicideandhomicide/violenceare consideredunnaturalcauses,whiletheother somestudieshavelookedintotheriskofcancer,butresultshavebeencategoryisusedin inconclusive(Calabriaetal.,2010;Chenetal.,2008;Hall,Christie,&caseswhereitcannotbedeterminedwhetherthedeathwasnatural Currow,2005;Hashibeetal.,2005;Mehra,Moore,Crothers,Tetrault,orunnatural(DanishHealthandMedicinesAuthority,2008a).Aside &Fiellin,2006).However,theliteraturethatexistsonspeciccausesfromthisthereare ICD-10 codesforfurtherspecicationoftheclinical ofdeathamongcannabisusersispredominantlycross-sectionalandcauseofeventsleadingtodeath.Thisarticleonlycontainsdataonthe knowledgeisparticularlysparseinrelationtoheavycannabisuse/overallcauseofdeathandnotthespecic ICD-10 codes.Registrations individualswithcannabisusedisorders.endedonDecember31,2006(DanishHealthandMedicines Weperformedalongitudinalfollow-upstudyincludingallAuthority,2008b).TheDanishCivilRegistrationsystemwasusedto individualsintreatmentforcannabisusedisordersinDenmarkidentifysubjectswhodiedafterthisdate,butcausesofdeatharenot from1996onwardsbyusingnationwideregistersforsubstanceuseavailablefortheseindividuals. disorders,psychiatricdisorders,andcausesofdeath.ThefollowingTheDanishCivilRegistrationSystem(Pedersen,Gøtzsche,Møller, researchquestionswereaddressed:&Mortensen,2006),establishedin1968,includesallpersonsalive andresidinginDenmark.Amongothervariables,itcontains 1.Whichfactorsareassociatedwithincreasedhazardsof informationonCivilRegistrationSystemnumberandcontinuously mortality? updatedinformationonvitalstatus.EachDanishcitizenisascribeda 2.WhataretheSMRsforspeciccausesofdeath? uniqueCivilRegistrationSystemnumberandthisisusedasapersonal identierinallnationalregisters,thusenablingaccuratelinkage 2.Materialandmethods betweentheregistersusedinthestudy. TheDanishPsychiatricCaseRegister,establishedin1967,(Munk- 2.1.Studypopulation Jorgensen&Mortensen,1997)wasusedtoinvestigatethepotential roleofcomorbidpsychiatricdisordersinrelationtomortality.Those Thesampleconsistsof6445personswhoreceivedtreatmentwhohadreceivedtreatmentforanypsychiatricdisorder,excluding substanceusedisorders,werecomparedtothosewhohadnot.For forcannabisusedisordersinallspecializedinstitutionsforsub- stanceusedisordersinDenmarkbetweenJanuary11996andfurtherdescriptionoftheregisterseeArendt,Rosenberg,Foldager, Perto,andMunk-Jorgensen(2007). December312006. MortalityratesfromthegeneralDanishpopulationwere 2.2.Informationfromregisters retrievedfromapublicregisterrunbyStatisticsDenmark(Statistics Denmark,2009). TheDanishSubstanceAbuseTreatmentRegister(DanishHealthThestudywasapprovedbytheDanishDataProtectionAgency. andMedicinesAuthority,2006)wasusedtoidentifypersonsin treatmentforcannabisusedisorders.Furtherinformationonvital 2.3.Dataanalysis status,causesofdeathandpsychiatrictreatmentwasretrievedforall ofthosewhohadreceivedsuchtreatment.ThelinkagewasbasedonStandardizedmortalityratios(SMR)werecalculatedbydividing theCivilRegistrationSystemnumberforeachofthecannabisusers.observedratesofdifferentcausesofdeathwithexpectedratesinage Standardizedmortalityratioswereestablishedbycomparingwithandgenderstratiedindividualsfromthebackgroundpopulation.Data mortalitystatisticsfromthegeneralDanishpopulation.onthebackgroundpopulationwereavailablefor1-yearagestrata,for TheDanishSubstanceAbuseTreatmentRegisterwasestablisheddifferentcausesofmortality,andformalesandfemalesseparately. in1996anditcontainsinformationonallindividualsreceivingAnumberofsociodemographicandsubstancerelatedvariables treatmentforsubstanceusedisordersinpubliclyfundedinstitutions.wereassessedatbaseline.Hazardratios(HR)ofall-causemortality duringfollow-upweredeterminedforeachvariableseparatelybyuse Thereareonlyfewprivatelyoperatedsubstanceabusetreatment institutionsinDenmarkexceptforalcoholusedisorders.SincetheofCoxproportionalhazardsregressionanalyses.Variablessigni- presentstudyisconcernedwithcannabisusedisorders,thismeanscantlyassociatedwithall-causemortalityinunivariateanalyseswere thatpracticallyalltreatmentiscovered.TheregistercontainsenteredintoamultivariateCoxproportionalhazardsregression demographicaswellassubstancerelatedinformation.Thesubstancemodelandadjustedestimatesreported.Variablespredictingeachof usersareregisteredwithoneprimarysubstanceofabusewhileitisthedifferentcausesofdeathweresimilarlydeterminedbyuseofCox possibletohavenumeroussecondarydrugsofabuse.Unfortunately,proportionalhazardsanalyses.Allvariableswereenteredwith alcoholmisuseisnotincludedamongthesecondarydrugsofabuse.Itbackwardselectionandadjustedhazardratiosforvariablessigni- ispossibletoberegisteredwithnomainsubstanceincaseofcantlyassociatedwitheachoutcomearereported. simultaneoususeofseveralsubstancesmakingitimpossibletoInallanalyses,timeatriskwascalculatedfromtherstdayofthe determineaprimarysubstance.Regrettably,allsubstanceuseisonlyrstregisteredtreatmentepisodeanduntileitherdeath,emigration, registeredforthemonthbeforetreatmententry.ThevariableorDecember31,2006.ForallSMRsandhazardratios,95%condence injectiondruguseisavailableforlifetimebeforetreatment.Thoseintervals(CI)werecalculated.Statastatisticalsoftwarewasusedfor whoreportedcannabisasprimarysubstanceofabusewereselectedallanalyses(StataCorp,2007). forthepresentstudy.Finally,theregisterspecieswhethertreatment wassuccessfullycompletedorterminatedforotherreasons.Theterm 3.Results cannabisusedisorderisusedeventhoughitcouldnotbedetermined thattheparticipantsfullledformaldiagnosticcriteria.However,itis 3.1.Samplecharacteristics assumedthattheysufferedfromsuchdisorderssincetheyreceived treatmentinordertoceasetheuseofcannabis.Thestudypopulationof6445individualsintreatmentfor TheDanishRegisterofCausesofDeathwasusedtoidentifydeathscannabisusedisorderswerefollowedfor4.1yearsonaverage followingsubstanceabusetreatment.Theregistercontainsinforma-(median=3.4;25percentile=1.7;75percentile=6.1years).Atthe tionondatesandcausesofdeathsforallDanishcitizens(Helweg-timeofrsttreatmentcontactthemeanagewas26years 402 M.Arendtetal./JournalofSubstanceAbuseTreatment44(2013)400406 Table2 (median=24;25percentile=20;75percentile=30years).As Substanceuseandtreatmentrelatedvariablesassociatedwithmortalityin6445 evidentfromTable1,thesamplepredominantlyconsistedof individualstreatedforcannabisusedisorders. males,borninDenmark,withalowlevelofeducation,without Characteristic%No.ofPerson-MortalityrateUnadjusted children,andlivingalone.Manyusersreenteredtreatmentoverthe deathsyearsdeaths/1000hazardratio follow-upperiodandthemeannumberoftreatmentcoursesafter person-years\[95%CI\] indexwas1.4(standarddeviation:2.9). \[95%CI\] Table2includesinformationrelatedtosubstanceuseand Ageatrstuseofcannabis treatment.Cocaineoramphetaminehadbeenusedby26%,and 16ormore354180885.1\[3.7 6.9\]1 opioidsby6%,inthemonthbeforeenteringtreatment.Twenty-four 13 15years525211,1624.7\[3.6 6.1\]0.92\[0.61 1.38\] percentreportedanylifetimeinjectiondruguse.Mostreceived b 13years131930516.2\[4.0 9.8\]1.23\[0.71 2.12\] a Opioiduse outpatienttreatment(90%)fortheircannabisusedisorderand15% No9411724,6744.7\[4.0 5.7\]1 hadreceivedtreatmentforapsychiatricdisordereitherbeforeorafter Yes625191013.1\[8.9 19.4\]2.76\[1.79 4.26\] receivingsubstanceabusetreatment. a Cocaine/amphetamineuse No7410319,7905.2\[4.3 6.3\]1 Yes263967945.7\[4.2 7.9\]1.10\[0.76 1.59\] 3.2.Predictorsofall-causemortality Everinjecteddrugs No765914,0054.2\[3.3 5.4\]1 Onehundredforty-twodeathswererecordedover26,584person- Yes244862387.7\[5.8 10.2\]1.67\[1.18 2.37\] Treatedasinpatient yearsofobservation.Itwasdeterminedwhetherspecicsocio- No908215,6515.2\[4.2 6.5\]1 demographicfactors,aswellasvariablesrelatedtosubstanceuseand Yes101623056.1\[3.6 10.3\]1.19\[0.67 2.13\] treatment,assessedatbaseline,wereassociatedwithall-cause Successfullycompletedtreatment mortalityduringfollow-up.Univariateanalysesshowedthatage, Yes351948333.9\[2.5 6.2\]1 comorbiduseofopioids,andlifetimeinjectiondrugusewere No654489164.9\[3.7 6.6\]1.27\[0.74 2.17\] b Psychiatriccomorbidity associatedwithhigherhazardsofall-causemortality(seeTables1 No858618,8774.6\[3.7 5.6\]1 and2).Nodifferenceswereobservedforgender,immigrantstatus, Yes priorto111024104.1\[2.2 7.7\]0.66\[0.34 1.29\] levelofeducation,havingchildren,partnerstatus,ageatrstcannabis treatment use,cocaine/amphetamineuse,inpatient/outpatienttreatment,suc- Yes following4716494.2\[2.0 8.9\]0.96\[0.44 2.08\] treatment cessfulcompletionoftreatment,orhistoryofpsychiatrictreatment. a Next,signicantvariablesfromtheunivariateanalyseswere Inthemonthbeforetreatmententry. b includedinamultivariateanalysis,andadjustedhazardratios Excludingtreatmentforsubstanceusedisordersinapsychiatricsetting. estimated.Thestrongesteffectonall-causemortalitywasobserved foropioiduseinthemonthpriortotreatmentstart(adjustedhazard ratio:2.34,95%CI1.51 3.64,p b.001).Lifetimeinjectiondrugusereasonfordeathwithinthesamplewasaccidents.Comparedwithage (adjustedhazardratio:1.45,95%CI1.02 2.07,p b.001)andhigherageandgenderstratiedratesfromthegeneralpopulationthiswasalso (adjustedhazardratio:1.05,95%CI1.03 1.07,p b.001)werealsothespeciccauseofdeathwithhighestexcessmortality(SMR:8.2, signicantlyassociatedwithall-causemortality. 95%CI:6.3 10.5).Suicideoccurredapproximatelyvetimesmore frequentlycomparedwiththebackgroundpopulation,whilehomi- cideoccurredapproximatelyfourtimesasoften.Deathfromnatural 3.3.Causesofdeath causes,includingalldiseases,wasthreetimesmorecommon. Allbaselinevariables(age,gender,immigrantstatus,education, Excessmortalityfordifferentcausesofdeathwasestimatedby children,livingwithpartner,ageatrstcannabisuse,opioidusein comparingcannabisuserswithindividualsfromthegeneralpopula- themonthpriortotreatmentstart,cocaine/amphetamineuseinthe tionofsameageandgender.Thesestandardizedmortalityratiosare monthpriortotreatmentstart,lifetimeIVuse,treatedasinpatient, includedinTable3alongwithcrudedeathrates.Themostcommon successfullycompletedtreatment,andpsychiatriccomorbidity)were enteredbackwardsintoCoxproportionalhazardmodelsaspredictors Table1 ofeachofthespeciccausesofdeathincludedinTable3(accidents, Hazardsforall-causemortalityin6445individualstreatedforcannabisusedisorders. suicide,homicide/violence,andnaturalcauses).Thesefouranalyses Characteristic%ofNo.ofPerson-MortalityrateUnadjusted revealedthatdeathfromaccidentswaspredictedbyopioiduse sampledeathsyearsdeaths/1000hazardratio (adjustedhazardratio:4.0,95%CI2.2 7.5,p b.001),homicide/ person-years\[95%CI\] violencewaspredictedbyopioiduse(adjustedhazardratio:24.6, \[95%CI\] 95%CI4.5 134.6,p b.001),deathfromnaturalcauseswaspredicted Age1.06\[1.04 1.08\] byhigherage(adjustedhazardratio1.13,95%CI1.10 1.17,p b.001), Gender whilesuicidewasnotpredictedbyanyofthevariables.Allother Female202152694.0\[2.6 6.1\]1 Male8012121,3155.7\[4.8 6.8\]1.43\[0.90 2.27\] variableswerenotassociatedwithanyofthespeciccausesofdeath. Immigrantstatus Becauseoftheclearassociationbetweenco-morbidsubstanceuse Non-immigrant9611722,6315.2\[4.3 6.2\]1 andmortality,SMRsforeachspeciccauseofdeathwerecalculated Immigrant448214.9\[1.8 13.0\]0.91\[0.34 2.46\] forindividualswhoreportednouseofopioidsorstimulantsinthe Education monthbeforeenteringtreatmentandnolifetimeinjectiondruguse Medium/long335715.3\[1.7 16.3\]1 education (seeTable3).TheSMRforhomicide/violencewasnolonger Shorteducation253258275.5\[3.9 7.8\]1.06\[0.33 3.48\] signicantlyelevatedandtheestimateforaccidentslower,while Elementary738217,6164.7\[3.8 5.8\]0.89\[0.28 2.81\] theremainingestimateswerelargelyunaffected. schoolonly Children Yes132136825.7\[3.7 8.8\]1 3.4.Timeofdeathinrelationtotreatment No8711321,8645.2\[4.3 6.2\]0.93\[0.58 1.47\] Livingwithpartner Yes202254534.0\[2.7 6.1\]1 Standardizedmortalityratiosforspecictimeintervalsfollowing No8011220,0745.6\[4.6 6.7\]1.38\[0.88 2.18\] thebeginningandendoftreatmentwerecalculated.Table4shows M.Arendtetal./JournalofSubstanceAbuseTreatment44(2013)400406 403 Table3 a Standardizedmortalityratios(SMR)fordifferentcausesofdeathfollowingstartoftreatmentforcannabisusedisorders. b AccidentSuicideHomicide/violenceNaturalcausesOther/unknownTotal Numberofdeaths602164114142 Cruderatesdeathsper1000person-years2.3\[1.7 2.9\]0.8\[0.5 1.2\]0.2\[0.1 0.5\]1.5\[1.1 2.1\]0.5\[0.5 1.2\]5.3\[4.5 6.3\] \[95%CI\] SMR\[95%CI\]8.2\[6.3 10.5\]5.3\[3.3 7.9\]3.8\[1.5 7.9\]2.8\[2.0 3.7\]12.0\[6.5 20.4\]4.9\[4.2 5.8\] SMRexcludingusersofopioids,cocaine,5.2\[3.2 8.0\]4.8\[2.4 8.9\]1.4\[0.1 7.1\]3.0\[1.8 4.7\]4.4\[0.7 14.5\]3.9\[2.9 5.1\] amphetamine,orinjectiondruguse c \[95%CI\] a Standardizedwithrespecttoageandgender. b Coversalldiseases. c Opioid,cocaine,andamphetamineuseisreportedforthemonthbeforetreatmententry.Injectiondruguseisreportedforlifetimebeforetreatmententry. thattheSMRswereparticularlyhighinthe2weeksfollowingpeared.Sidneyetal.(1997)studiedalargecohortenrolledina treatmentstart.Fourdeathswererecordedwithinthistime-frame.medicalcareprogram.Lifetimemarijuanauseonmorethansix occasionsaswellascurrentusewereassociatedwithincreasedAIDS Twoofthediseasedreportedlifetimeinjectiondruguseandtheother twosecondaryuseofamphetamineorcocaine.Followingtreatmentmortalityinmen,butnotwithothercausesofdeath.Basedonthese entry,theSMRswerelowestinthetimeintervalsfrom2weeksuntilndings,itissurprisingthatothervariableswerenotassociatedwith theendoftherstyear.SMRswerenotclearlylowerinthetimeall-causemortality. periodimmediatelyaftertheendoftreatmentneitherfortheentire populationnorforthegroupofuserswhowereterminatedfollowing 4.2.Overallmortality successfultreatment. Thoseintreatmentforcannabisusedisorderswerevetimes 4.Discussion morelikelytodieduringfollow-upcomparedwithindividualsfrom thegeneralpopulationofsameageandgender.Wahrenetal.(1997) ThisistherstlongitudinalstudytofollowalargenationwidehavepreviouslyreportedSMRsof8.0and7.4,intwocohortsfollowed cohortofpersonstreatedforcannabisusedisordersinordertofrom1971to1972andfrom1981to1982,amongcannabisuserswho establishcausesofsubsequentdeath.Inthissectionwewillhadbeenhospitalizedforeithersomaticorpsychiatricproblems.They summarizethemainndingsanddiscusstheminrelationtothedidnotreportonpredictorsofdeathorcausesofdeathspecicallyfor existingliterature.cannabisusers.Thelowerestimateinthecurrentstudycouldbe explainedbythefactthatmanyreceivedoutpatienttreatment. 4.1.Predictorsofall-causemortality 4.3.Accidents Highage,opioiduse,andlifetimeIVusewerepredictorsofall- causemortalityduringfollow-up.ThefactthatopioiduseintheWefoundthataccidentaldeathwasthemostcommonspecic monthpriortotreatmentpredictedthehazardofmortalityiscauseofdeathinabsolutenumbersandthesamplewasovereight consistentwiththesignicantlyhighermortalityratesobservedtimesmorelikelytodiefromthiscausecomparedwithageand amongprimaryusersofopioids(Hulse,English,Milne,&Holman,gendermatchedindividualsfromthegeneralpopulation.Noother 1999).However,secondaryuseofopioidswasreportedbyonly6%incohortstudyhasexploredthesignicanceofcannabisusedisordersat oursample,andevenafterexclusionoftheseindividualstherewasabaselineforlatermortalityduetoaccidents.However,anassociation betweencannabisuseandinjuries,andespeciallytrafcaccidents, highlevelofexcessmortality.Whetheropioidusedevelopedduring follow-upwasnotassessed,butwehavepreviouslyreportedthathaspreviouslybeenreported(Kalant,2004;Macdonaldetal.,2003; 10.4%intreatmentforcannabisusedisordersreceivedtreatmentforRamaekers,Berghaus,Van,&Drummer,2004;Sewell,Poling,& opioidusedisordersatalaterpointintime(Arendtetal.,2007).AllinSofuoglu,2009).Themajorityoftheexistingstudiesconcerndrivers all,itthusseemsreasonabletoconcludethatcomorbidopioiduseinvolvedincrasheswhoweresubsequentlytestedforthepresenceof explainedsome,butnotall,oftheexcessmortality.cannabis(Biecheler,Peytavin,Facy,&Martineau,2008;Brodie, TwocohortstudieshavereportedontheassociationbetweenLyndal,&Elias,2009;Drummeretal.,2003;Eksborg&Rajs,2008; cannabisuseandall-causemortality.BothfoundthatcannabisuseasLaumonetal.,2005;Muraetal.,2006). wellasanumberofotherbaselinevariableswerehighlyassociatedTworetrospectivecohortstudieshaveexaminedassociations withsubsequentdeath.AndreassonandAllebeck(1990)performedabetweenbaselinecannabisuseandsubsequentinvolvementin studyonSwedishconscriptsandfoundthatlifetimecannabisuseoveraccidents.FergussonandHorwood(2001)andFergusson,Horwood, 50timeswasassociatedwitharelativeriskof2.8.However,followingandBoden(2008)reporteddatafromtwoseparatetimepointsina adjustmentforsocialbackgroundvariablestheassociationdisap- follow-upstudyfromNewZealand.Inbothstudiestherewerelinks Table4 a Standardizedmortalityratios(SMR)associatedwithtreatmentstartandending. 2weeks N 2weeks N 1month N 3months N 1yearFullfollow-up SMR\[95%CI\]1month3months1yearSMR\[95%CI\] SMR\[95%CI\]SMR\[95%CI\]SMR\[95%CI\] Deathsfollowingtreatmentstart17.3\[5.5 42.0\]03.3\[1.2 7.4\]2.5\[1.5 4.0\]4.9\[4.1 5.9\]4.9\[4.2 5.8\] Deathsfollowingendoftreatment03.5\[0.2 17.0\]4.7\[1.5 11.2\]2.9\[1.5 5.2\]4.3\[3.2 5.7\]5.8\[4.4 7.4\] b Deathfollowingsuccessfulendoftreatment011.4\[0.6 56.1\]03.8\[0.2 18.5\]3.8\[2.1. 6.5\]4.4\[2.5 7.3\] a Standardizedwithrespecttoageandgender. b Estimatesforthe35%ofthepopulationwhosuccessfullycompletingtreatment. 404 M.Arendtetal./JournalofSubstanceAbuseTreatment44(2013)400406 betweencannabisuseandtheriskofbeinginvolvedinanaccident.indicatethatcannabiscouldcausedeathfromthiscauseamong However,followingadjustmentforconfounders,includinguseofindividualswithexistingvulnerability(Mukamaletal.,2008)but alcoholandrisktakingbehavior,theassociationswerenolongermoreevidenceisneededbeforermconclusionscanbedrawn. signicantineitherstudy.Gerberichetal.(2003)foundthatmenwhoUnfortunately,inthecurrentstudyitwasnotpossibletoprovide werecurrentusersofcannabisatbaselineweremorelikelytoex-estimatesofSMRsforspecicdiseases.Also,itwasnotfeasibleto perienceanyinjuryrequiringhospitalization,andspecicallymotoradjustfortheeffectsofuseofothersubstancessuchastobaccoor vehicleaccidents,assaults,andself-inictedinjuryduringfollow-up.alcohol,orfactorsassociatedwithanunhealthylifestyle(e.g. Womenwhowerecurrentusersabaselinehadhigherratesofmalnutrition,lackofexercise).Therefore,itislikelythatsomeof all-causeinjuryandself-inictedinjury.However,thestudiesaretheexcessmortalitycanbeexplainedbycausesasidefrom allconcernedrelativelyinfrequentcannabisusersratherthanindi-cannabisuse. vidualswithcannabisdisordersasinthecurrentstudy. 4.7.Protectiveeffectsoftreatment 4.4.Suicide Fourdeathswererecordedduringtherst2weeksoftreatment, Suicideoccurredvetimesasfrequentlyduringfollow-upinourbutinallcasesthiscouldbeexplainedbyuseofstimulantsor samplecomparedwithindividualsfromthegeneralpopulation.Ainjectiondruguse.ThelowestSMRswerefoundbetween2weeksand longitudinalstudybyPriceetal.(2009)alsofoundanassociationtherstyearaftertreatmentstartindicatingthatbeingintreatment betweenbaselinecannabisuseandcompletedsuicideatalaterpointincouldbeprotective.Incontrast,aprotectiveeffectfollowingtheend time,buttheassociationdisappearedfollowingadjustmentforresidualoftreatmentcouldnotbedemonstrated.Therearenopublicationson confounding.Atleastthreecohortstudieshaveinvestigatedcannabismortalityamongpeopleintreatmentforcannabisusedisorderswith useasapredictorofsuicidalideationorsuicideattempts(Fergusson,whichresultscanbecompared. Horwood,&Swain-Campbell,2002;Pedersen,2008;Wilcox& Anthony,2004).Allstudieshavefoundthatcannabisusepredictthe 4.8.Strengthsandlimitations outcomes,butonlyforspecicageorgender-relatedsubgroups.A numberofcross-sectionalorretrospectivestudieshavefoundanThestudyhasseveralstrengthscomparedtotheexisting associationbetweencannabisuseandsuicidalideation,suicidescienticliteratureoncannabisandmortality.First,thenumberof attempts,orcompletedsuicide(Beautraisetal.,1999;Chabroletal.,individualswithcannabisusedisorderswaslarge.Second,the 2008;Huasetal.,2008;Kung,Pearson,&Liu,2003;Lynskeyetal.,samplewasfollowedovertimeandnumberofperson-years 2004).Thisassociationcouldbedose-related,withhigherrisksamongsubstantial.Third,anumberofspecicreasonsfordeathwere heavierusers(Fergussonetal.,2002;Huasetal.,2008;Pedersen,assessed,includingsomeforwhichnopreviouscohortstudieshave 2008).However,associationshaveoftenbeenmarkedlylower,orevenbeenpublished.Fourth,mortalityrateswerecomparedwithin- non-signicant,followingadjustmentforresidualconfounding.Thedividualsfromthegeneralpopulationofsameageandgender. factthatresultsfromotherstudiesareoftenbasedoninfrequentFinally,onlyindividualswithcannabisusedisorderswereincluded. cannabisusers,cross-sectionaldesignsorshortfollowupintervalsThefewotherexistingcohortstudiesconcernrelativelyinfrequent complicatesacomparisonwiththeresultsofthecurrentstudy.usersofcannabisforwhompotentialdamagingeffectsaretherefore lesslikelytobedetected. 4.5.Homicide/violence Limitationsincludethefollowing.Thesampleconsistedofindi- vidualsintreatmentforcannabisusedisorders.Ratescouldtherefore TheSMRforhomicideorviolentdeathwasapproximatelyfour.beinatedduetothepresenceofclinicalproblems.Conversely, Welocatednocohortstudiesdescribingthisoutcomeamongin-successfultreatmentcoulddeateestimates.Thismeansthatresults dividualswithcannabisusedisorders.However,postmortemstudiescannotbeuncriticallygeneralizedoutsidesubstanceabusetreat- showthatcannabisisfrequentlydetectedinmurdervictims(Darke&mentsettings.However,thisisacommonprobleminresearchon Duou,2008;Eksborg&Rajs,2008;Galea,Ahern,Tardiff,Leon,&mortalityassociatedwithalltypesofsubstanceusedisorders.The Vlahov,2002;Macdonaldetal.,2003).Comorbidopioidusewas vastmajorityofstudiesarethusconcernedwithtreatmentseekers foundtobeastrongpredictorofhomicide/violenceandnoexcess(e.g.Degenhardt,Hall,&Warner-Smith,2006;Wilcox,Conner,& mortalityforthiscausewasobservedamongcannabisusersCaine,2004). withoutsecondaryopioidorstimulantuse.ThisindicatesthattheAnotherlimitationisthelackofcontrolforsomepotentially excessofhomicidescouldresultfromthelifestyleassociatedwithimportantconfoundersintheevaluationsofcausesofdeath.Arelated useofopioids.issueisthatproportionalhazardsanalyseswereallperformedwithin agroupofindividualswithcannabisusedisorders.Asawhole,this 4.6.Naturalcause groupdiffersinseveralimportantwaysfromthegeneralpopula- tion.Forexample,thedemographicdatashowthatthelevelof Naturalcause,includingalldiseases,wasthesecondmosteducationwaslowandthatmanylivedofsubsidiesfromthestate. commoncauseofdeath.ComparedwithpersonsofsameageandToestablishwhethercannabiscausethehighlevelofmortalityitis genderthosewithcannabisusedisorderswerethreetimesaslikelytopreferabletocomparewithnon-users,forexamplebystudyinga dieduringfollow-upfromdiseases.Apotentialassociationbetweencohortincludingbothindividualswithandwithoutcannabisuse cannabisuseandcancerhasbeeninvestigatedinanumberofdisorders.Ontheotherhand,asidefromage,noneofthesocio- studies(Halletal.,2005;Hashibeetal.,2005;Mehraetal.,2006).demographicvariableswereassociatedwithincreasedmortality Theexistingreviewsallconcludethattheevidenceisconicting,butamongindividualsinthecurrentstudy.Bearingthislimitationin thatthereisreasontosuspectthatcannabiscancausesomecancermind,itcanbermlyconcludedthatindividualsintreatmentfor forms.Cautioniswarranted,however,sincemoststudiessufferfromcannabisusedisordershaveahighlevelofexcessmortality,overall severelimitations,suchassmallsamplesizes,retrospectivedesigns,aswellasforaccidents,suicides,andnaturalcauses,butalsothat andparticularlytheproblemofrulingouttheconsequencesofthereasonsfortheseassociationsshouldbefurtherexploredin tobaccosmoking(Chenetal.,2008).Therearesomestudiesonfuturestudies. cardiovascularfatalityrelatedtocannabisuse(Bachs&Morland,Theuseofregistersisassociatedwithseverallimitations. 2001;Sidney,2002;Westover,McBride,&Haley,2007).ResultsUnfortunatelythesubstanceabusetreatmentregisteronlycontains M.Arendtetal./JournalofSubstanceAbuseTreatment44(2013)400406 405 Degenhardt,L.,Hall,W.,&Warner-Smith,M.(2006).Usingcohortstudiestoestimate informationoncomorbidsubstanceuseduringthemonthpriorto mortalityamonginjectingdrugusersthatisnotattributabletoAIDS.Sexually treatmententry.Opioidorstimulantuseatanearlierpointcould TransmittedInfections,82,iii56 iii63. thusbepresent.Ontheotherhand,thereisinformationon Drummer,O.H.,Gerostamoulos,J.,Batziris,H.,Chu,M.,Caplehorn,J.R.,Robertson,M. 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LETTERTOTHEEDITOR Theimpactofadolescentcannabisuse,mood disorderandlackofeducationonattemptedsuicide inyoungadulthood Suicideisoneoftheleadingcausesofdeathworldwideeducationwerethemoststronglypredictivefactorsfor amongyoungpeople.Oneofthestrongestpredictorsofmakingasuicideattemptwhentheeffectsoffamilypsychi- completedsuicideisaprevioussuicideattempt(1).Sui-atrichistory,childhoodtrauma,alcoholuseandotherpsy- cideattemptsaremorefrequentamongyoungpeople,andchopathologyweretakenintoaccount. asuicideattemptmaybeamarkerofalastingtrajectoryofAdolescentmooddisorderandadolescentcannabisuse adversementalandphysicalproblemsintomiddleadult-bothindependentlyincreasedtheoddsofasuicide attempt7-fold(OR 5 7.0,95%CI:1.4-34.3;OR 5 7.5,95% hood(1,2).Thereislimitedevidenceforfactorsduringthe adolescentperiodandtheperiodoftransitiontoyoungCI:1.2-43.8),whileyoungadultmoodandanxietydisor- adulthoodthatincreasetheriskofattemptedsuicide.Wedersbothindependentlyincreasedtheoddsofanattempt usedaprospectivecohortstudydesignincorporating11-fold(OR 5 11.7,95%CI1.8-73.9;OR 5 11.1,95%CI: clinicalinterviewstodeterminewhatfactorsmeasuredat21.0-57.9).Youngadultswithonlysecondary-leveleduca- ages12-15yearsareassociatedwithattemptedsuicidetionhadan8-foldincreaseintheoddsofasuicideattempt reportedatages19-24years.comparedtothosewiththird-leveleducation(OR 5 8.0, Themethodsforthebaselineadolescentstudyhaveprevi-95%CI:1.1-54.4). ouslybeendescribed(3).UsingastratiÐedrandomsamplingThereisevidencethatsubstanceusedisordersinadult- technique,743studentsineightmainstreamschoolswerehoodincreasetheriskofsuicidalbehaviours.Herewe screenedforpsychopathology.Adolescentswhoscoredshowthatanyuseofcannabisintheearlyadolescentperi- abovethresholdonthescreeninginstrumentsorwhoindi-odisastrongindependentpredictorofattemptedsuicide catedthepresenceofsigniÐcantsuicidalideation(N 5 140)inyoungadulthood.WeknowthatsigniÐcantbrainmatu- wereinvitedtoattendforinterview,alongwithagroupofrationcontinuestooccurduringadolescence,particularly 174controlsmatchedforgender,schoolandschoolyear.inlimbicstructuressuchasthehippocampus;andwithin 84.3%adolescentsfromtheÅatriskÆcategoryand54%oftheprefrontalcorteximportantprocessessuchassynaptic thecontrolgroupattendedforasemi-structuredclinicalpruning,myelinationandprogrammingofneurotrophic interview,alongwithaparentorguardian.All212younglevelsareoccurringatthistime(4).Regularcannabisuse peoplewhowereinterviewedasyoungadolescentswerecanleadtogreymattervolumereductioninarangeof invitedtotakepartinafollow-upintervieweightyearslater.brainareas,includingthemedialtemporalcortex,thepar- Follow-upinformationwasobtainedon168participantsahippocampalgyrus,theinsulaandorbitofrontalregions (79%follow-uprate).Therewerenodifferencesbetween(5).Thereisevidenceofalinearassociationbetweenthe respondersandnon-respondersinage,gender,parentalageatonsetofcannabisuseandbothwhitematterintegrity socio-economicstatus,Åat-riskÆstatusatbaseline,ordiagno-andgreymattervolume,suggestingthattheearlierthe sisofpsychiatricdisorderatbaseline.onsetofuse,thegreaterthetoxiceffectsonthebrain(5,6). Wecollectedexposureinformationatinterviewon:Neuroimagingstudiesofpeoplewhohaveattemptedsui- familyandchildhoodriskfactors(familyhistoryofpsychi-cideshowstructuralandfunctionalbrainchangesthatare atricillnessandexperienceofchildhoodtrauma,i.e.phys-inkeepingwiththosefoundincannabisusers(7).Itispos- ical/sexualabuseorwitnessingdomesticviolence);ado-siblethatcannabisuseinearlyadolescence,atavulnerable lescentriskfactors(psychopathology,cannabisuseandtimeforneurodevelopment,leadstoorexacerbatesongo- alcoholuse);youngadultriskfactors(psychopathology,ingdysfunctionalbrainchangesthatprimeyoungpeople cannabisuse,self-harm,educationlevelandemploymentforamaladaptivetrajectorytowardsyoungadulthood. Thosemostatriskforattemptedsuicidemayhaveexperi- status).Theoutcomemeasurewaslifetimesuicide attemptsat19-24yearsold.encedaccumulatingriskexposuresthroughoutchildhood Tenpercentofparticipantshadmadeasuicideattemptandadolescenceandinyoungadulthoodmaylackade- atsomepointintheirlivesuptoage19-24years.Themeanquateproblemsolvingskills,aspossiblyindexedhereby ageofthoseattemptingsuicidewas20.6years.Fifty-threelowlevelsofeducation. percentofthosewhoreportedasuicideattemptwereTheincreasingawarenessamongthementalhealth female.Hierarchicallogisticregressionmodelsshowedthatcommunitythatweneedtofocusonearlyclinicalinter- adolescentmooddisorderandadolescentcannabisuse,ventiontoprotectagainsttheworsteffectsofemotional youngadultmoodandanxietydisorders,andalowlevelofdistressamongouryoungpeople,bothonapersonaland 322 WorldPsychiatry13:3-October2014 aneconomiclevel(8),canonlybeactedonwhenwecan References reliablyidentifywhichyoungpeoplearemostatrisk.The 1.CrosbyAE,HanB,OrtegaLAetal.Suicidalthoughtsandbehav- availableevidencesuggeststhatthespecialisttreatmentof iorsamongadultsaged/5 18years-UnitedStates,2008-2009. psychiatricdisorderinadolescencealoneisinsufÐcient MMWRSurveillSumm2011;60:1-22. forthepreventionoffuturesuicideattempts(9).Weneed 2.Goldman-MellorSJ,CaspiA,HarringtonHetal.Suicideattempt amoretailoredapproachtoyouthmentalhealthanda inyoungpeople:asignalforlong-termhealthcareandsocial needs.JAMAPsychiatry2014;71:119-27. greaterawarenessofthedifferentcontingenciesinvolved 3.HarleyM,KelleherI,ClarkeMetal.Cannabisuseandchildhood inthepathwaytosuicidalbehaviourssuchasaccumulat- traumainteractadditivelytoincreasetheriskofpsychoticsymp- ingriskfromadolescentcannabisuse,adolescentmood tomsinadolescence.PsycholMed2010;40:1627-34. disordersandalackofeducation. 4.MaloneDT,HillMN,RubinoT.Adolescentcannabisuseand psychosis:epidemiologyandneurodevelopmentalmodels.BrJ 11 Pharmacol2010;160:511-22. MaryCatherineClarke,HelenCoughlan, 1,211 5.BattistellaG,FornariE,AnnoniJMetal.Long-termeffectsofcan- MichelleHarley,DearbhlaConnor,EmmetPower, 341 nabisonbrainstructure.Neuropsychopharmacology(inpress). FionnualaLynch,CaroleFitzpatrick,MaryCannon 6.ZaleskyA,SolowijN,YucelMetal.Effectoflong-termcannabis 1 RoyalCollegeofSurgeonsinIreland,Dublin,Ireland; useonaxonalÐbreconnectivity.Brain2012;135:2245-55. 2 St.VincentsHospital,Fairview,Ireland; 7.vanHeeringenK,MannJJ.Theneurobiologyofsuicide.Lancet 3 LucenaClinic,Dublin,Ireland;(inpress). 4 8.CoughlanH,CannonM,ShiersDetal.Towardsanewparadigm UniversityCollegeDublin,Dublin,Ireland ofcare:theInternationalDeclarationonYouthMentalHealth. EarlyIntervPsychiatry2013;7:103-8. 9.TuiskuV,KiviruusuO,PelkonenMetal.Depressedadolescents Acknowledgement asyoungadultsÃpredictorsofsuicideattemptandnon-suicidal self-injuryduringan8-yearfollow-up.JAffectDisord2014;152- 154:313-9. ThisworkwassupportedbyagrantfromtheHealth ResearchBoardHRA-PHS/2010/4. DOI10.1002/wps.20170 323 MARIJUANA AND VIOLENCE Recent science shows a clear relationship between marijuana use and violence. Violent episodes, particularly domestic violence, should be investigated to ascertain any involvement with marijuana. Marijuana use can also be a predictor of violence and thus preventing marijuana use can possibly prevent violence. A recent study showed that compared with never-users, those who use marijuana and are exposed to it effects (use at age 18, 32 and 48 years) were associated with a higher risk of subsequent violent behavior, as indicated by convictions or self-reports. This effect persisted even after the study controlled for other putative risk factors for violence. The study discovered a hi-directional relationship between marijuana use and violence. Marijuana use predicted subsequent violent behavior suggesting a possible causal effect. \[FN1\] A 2017 study showed that: Marijuana is currently a growing risk to the public in the United States. Following expanding public opinion that marijuana provides little risk to health, state and federal legislatures have begun changing laws that will significantly increase accessibility of marijuana. Greater marijuana accessibility, resulting in more use, will lead to increased health risks in all demographic categories across the country. Violence is a well-publicized, prominent risk from the more potent, current marijuana available. \[FN2\] There are many other studies showing a relationship between marijuana use and violence. \[FN3\] Footnotes \[FN1\] T. Schoeler, D.Theobald, J.-B. Pingaült, D. P. Farrington, W. G. Jennings, A. R. Piquero, J. W. Cold and S. Bhattacharyyal, “Continuity of cannabis use and violent offending over the life course.” Psychological Medicine (2016), 46, 1663-1677. Cambridge University Press 2016, doi:1O.1017/S0033291715003001 \[FN2\] Norman S. Miller and Thersilla Oberbarnscheidt, “Marijuana Violence and Law.” Journal of Addiction Research and Therapy, 2017, S11:014, DOI:10.4172/2155. 1000S11-014 \[FN3\] For other studies see: Bennett T, Holloway K, Farrington D (2008). The statistical association between drug misuse and crime: a meta-analysis. Aggression and Violent Behavior 13, 107-118. Bhattacharyya S, Atakan Z, Martin-Santos R, Crippa JA, Kambeitz J, Malhi S, Giampietro V, Williams S, Brammer M, Rubia K, Collier DA, McGuire PK (2015). Impairment of inhibitory control processing related to acute psychotomimetic effects of cannabis. European Neuropsychopharmacology 25, 26-37. Brook JS, Brook DW, Rosen Z, Rabbitt CR (2003). Earlier marijuana use and later problem behavior in Colombian youths. Journal of the American Academy of Child and Adolescent Psychiatry 42, 485-492. Brook JS, Lee JY, Finch SJ, Brook DW (2014). Developmental trajectories of marijuana use from adolescence to adulthood: relationship with using weapons including guns. Addictive Behaviors 40, 229-237. Chabrol H, Saint-Martin C (2009). Cannabis use and delinquent behaviors in high-school students. Addictive Behaviors 34, 187-189. Farrington DP (20 10). Commentary on Pedersen and Skardhamar (2010): does cannabis use predict non-drug offending? Addiction 105, 119-120. Fergusson DM, Horwood U, Swain-Campbell N (2002). Cannabis use and psychosocial adjustment in adolescence and young adulthood. Addiction 97, 1123-1135. McNaughton Reyes HL, Foshee VA, Bauer DJ, Ennett ST (2014). Proximal and time-varying effects of cigarette, alcohol, marijuana and other hard drug use on adolescent dating aggression. Journal of Adolescence 37, 281-289. Monshouwer K, Van Dorsselaer 5, Verdurmen J, Bogt TT, De GraafR, Vollebergh W (2006). Cannabis use and mental health in secondary school children Findings from a Dutch survey. British Journal of Psychiatry 188, 148-153. Norström T, Rossow 1(2014). Cannabis use and violence: is there a link? Scandinavian Journal of Public Health 42, 358-363. Patton GC, Coffey C, Uynskey MT, Reid 5, Hemphill 5, Carlin JB, Hall W (2007). Trajectories of adolescent alcohol and cannabis use into young adulthood. Addiction 102, 607-615. Pedersen W, Skardhamar T (2010). Cannabis and crime: findings from a longitudinal study. Addiction 105, 109-118. Peters EN, Schwartz RP, Wang 5, O'Grady KE, Blanco C (2014). Psychiatric, psychosocial, and physical health correlates of co-occurring cannabis use disorders and nicotine dependence. Drug and Alcohol Dependence 134, 228-234. Reingle JM, Staras SA, Jennings WG, Branchini J, Maldonado-Molina MM (2012). The relationship between marijuana use and intimate partner violence in a nationally representative longitudinal sample. Journal of Interpersonal Violence 27, 1562-1578. Schoeler T, Kambeitz J, Behlke I, Murray R, Bhattacharyya 5 (2016a). The effects of cannabis on memory function in users with and without a psychotic disorder: findings from a combined meta-analysis. Psychological Medicine 46, 177-188. Schoeler T, Monk A, Sami MB, Klamerus E, Foglia E, Brown R, Camuri G, Altamura AC, Murray R, Bhattacharyya 5 (2016b). Continued versus discontinued cannabis use in patients with psychosis: a systematic review and metaanalysis. Lancet Psychiatry. Published online 14 January 2016. doi:10.1016/52215-0366(15)00363-6. Schulenberg JE, Merline AC, Johnston LD, O'Malley PM, Bachman JG, Laetz VB (2005). Trajectories of marijuana use during the transition to adulthood: the big picture based on national panel data. Journal of Drug Issues 35, 255-280. Theobald D, Farrington DP (2012). Child and adolescent predictors of male intimate partner violence. Journal of Child Psychology and Psychiatry 53, 1242-1249. von Sydow K, Lieb R, Pfister H, Höfler M, Wittchen H-U (2002). What predicts incident use of cannabis and progression to abuse and dependence? A 4-year prospective examination of risk factors in a community sample of adolescents and young adults. Drug and Alcohol Dependence 68,49-64. United Nations Office on Drugs and Crime (2010). World Drug Report 2010. United Nations: New York (https://www.unodc.org/documents/wdr/WDR-201 0/WorldDmg_Reportj0 1 0_bres.pdf). Accessed January 2016. Wei EH, Loeber R, White HR (2004). Teasing apart the developmental associations between alcohol and marijuana use and violence. Journal of Contemporary Criminal Justice 20, 166-183. Windle M, Wiesner M (2004). Trajectories of marijuana use from adolescence to young adulthood: predictors and outcomes. Development and Psychopathology 16, 1007-1027. MARIJUANA AND MENTAL ILLNESS Marijuana use can cause impairment of memory, attention, motor skills, reaction time, and the integration of complex information and impaired cognition and other neurological damage.\[FN1\] Marijuana use may also trigger psychiatric illnesses including: mood disorder schizophrenia depression psychosis brain deficits memory problems substance abuse disorder and clinical dependence. \[FN2\] The 2016 United States Surgeon General report on addiction states that marijuana is a serious threat to the physical and mental health of our children and that its use is a major threat to public safety. \[FN3\] The American Psychiatric Association reports that current evidence supports, at a minimum, a strong association of marijuana use with the onset of psychiatric disorders. “Adolescents are particularly vulnerable to harm, given the effects of cannabis on neurological development.” \[FN4\] The National Institute on Drug Abuse (NIDA) research shows that up to 30 percent of marijuana users may develop some degree of problem use that can include addiction. Among young users, the drug may reduce thinking, memory, and learning functions. Marijuana use has also been linked to mental health problems, such as depression, anxiety, and suicidal thoughts among teens. \[FN5\] In 2017, the National Academy of Sciences (NAS) landmark report written by top scientists concluded after a review of over 10,000 peer-reviewed academic articles, that marijuana use is connected to, among other problems such as mental health issues (like psychosis, social anxiety, and thoughts of suicide) and learning, memory, and attention loss (possibly permanent in some cases). \[FN6\] A study discussed in a 2017 article in Scientific American shows that people who had consumed marijuana before age 18 developed schizophrenia approximately 10 years earlier than others. The higher the frequency of use the earlier the age of schizophrenia onset. Neither alcohol use nor genetics predicted an earlier time of inception, but marijuana did. Marijuana use during puberty is a major risk factor for schizophrenia. The more marijuana you take - and the higher the potency - the greater the risk. \[FN7\] A recent study found that marijuana use in youth is linked to bipolar symptoms in young adults.\[FN8\] Recent research shows that marijuana use is associated with an increased risk of prescription and opioid misuse disorders. \[FN9\] The United Nation Office on Drug and Crime had this to say about marijuana use and damage to mental health Although it is often seen as a less harmful drug, cannabis use poses several health risks. Even when used only once, cannabis may lead to panic attacks, paranoia, psychotic symptoms and other negative acute effects. The drug may also precipitate psychosis in vulnerable individuals and intensify symptoms in diagnosed schizophrenics. \[FN10\] While a psychotic reaction can occur following any method of use, emergency room responders have seen an increasing number of cases involving marijuana edibles. Some people (especially preteens and teens) who know very little about edibles don't realize that it takes longer for the body to feel marijuana’s effects when eaten rather than smoked. So they consume more of the edible, trying to get high faster or thinking they haven't taken enough. In addition, some babies and toddlers have been seriously ill after ingesting marijuana or marijuana edibles left around the house. \[FN11\] Footnotes \[FN1\] Abbie Crites-Leoni, Medicinal Use of Marijuana: Is the Debate a Smoke Screen for Movement Toward Legalization?, 19 J. Legal Med. 273, 280 (1998) (citing Schwartz, et al., Short-Term Memory Impairment in Cannabis-Dependent Adolescents, 143 Am. J. Dis. Child. 1214 (1989)). \[FN2\] Schizophrenia and cannabis use may share common genes, Science Daily, June 24, 2014, http://www.sciencedaily.com/releases/2014/06/140624093320.htm Adolescents in substance abuse treatment report using someone else's medical marijuana, Science Daily, July 31, 2012, http://www.sciencedaily.com/releases/2012/07/120731094622.htm Cannabis Use Mimics Cognitive Weakness That Can Lead to Schizophrenia, MRI Study Finds, Science Daily, November 2, 2012, http://www.sciencedaily.com/releases/2012/11/121102084632.htm A risk gene for cannabis psychosis, Science Daily, November 14, 2012 http://www.sciencedaily.com/releases/2012/11/121114083928.htm Adolescent pot use leaves lasting mental deficits, Developing brain susceptible to lasting damage from exposure to marijuana. Science Daily, August 27, 2012, http://www.sciencedaily.com/releases/2012/08/120827152039.htm How marijuana impairs memory, Science Daily, March 1, 2012, www.sciencedaily.com/releases/2012/03/120301143424.htm Cannabis use precedes the onset of psychotic symptoms in young people, study finds, Science Daily, March 3, 2011, http://www.sciencedaily.com/releases/2011/03/110301184056.htm Psychotic illness appears to begin at younger age among those who use cannabis, Science Daily February 8, 2011 http://www.sciencedaily.com/releases/2011/02/110207165434.htm Long-time cannabis use associated with psychosis, Science Daily, March 2, 2010 http://www.sciencedaily.com/releases/2010/03/100301165726.htm Daily Pot Smoking May Hasten Onset of Psychosis, Science Daily, December 21, 2009, http://www.sciencedaily.com/releases/2009/12/091220144936.htm Daily Consumption Of Cannabis Predisposes To Appearance Of Psychosis And Schizophrenia, Study Finds, Science Daily, March 26, 2009, http://www.sciencedaily.com/releases/2009/03/090325132328.htm Cannabis-Related Schizophrenia Set to Rise, Say Researchers, Science Daily, 26 March 2007, http://www.sciencedaily.com/releases/2007/03/070324132832.htm Malchow B, Hasan A, Fusar-Poli P, Schmitt A, Falkai P, Wobrock T., Cannabis Abuse and Brain Morphology in Schizophrenia: a Review of the Available Evidence. Eur Arch Psychiatry Clin Neurosci. 2013 Feb 263(1):3-13 Fratta W, Fattore L., Molecular Mechanisms of Cannabinoid Addiction. Curr Opin Neurobiol. 2013 Aug;23(4):487-92 Stefanis NC, Dragovic M, Power BD, Jablensky A, Castle D, Morgan VA. Age at Initiation of Cannabis Use Predicts Age at Onset of Psychosis: The 7 to 8 year Trend, Schizophrenia Bulletin, (2013) Mar 39(2):251-4 Jing Han, Philip Kesner, Mathilde Metna-Laurent, Tingting Duan, Lin Xu, Francois Georges, Muriel Koehl, Djoher Nora Abrous, Juan Mendizabal-Zubiaga, Pedro Grandes, Qingsong Liu, Guang Bai, Wei Wang, Lize Xiong, Wei Ren, Giovanni Marsicano. Acute Cannabinoids Impair Working Memory through Astroglial CB1 Receptor Modulation of Hippocampal LTD. Cell, 2012, Volume 148, Issue 5, 2 March 2012, Pages 1039-1050 Marta Di Forti, Conrad Iyegbe, Hannah Sallis, Anna Kolliakou, M. Aurora Falcone, Alessandra Paparelli, Miriam Sirianni, Caterina La Cascia, Simona A. Stilo, Tiago Reis Marques, Rowena Handley, Valeria Mondelli, Paola Dazzan, Carmine Pariante, Anthony S. David, Craig Morgan, John Powell, Robin M. Murray. Confirmation that the AKT1 (rs2494732) Genotype Influences the Risk of Psychosis in Cannabis Users. Biological Psychiatry, 2012; 72 (10): 811 Wolitzky-Taylor K, Bobova L, Zinbarg RE, Mineka S, Craske MG., Longitudinal Investigation of the Impact of Anxiety and Mood Disorders in Adolescence on Subsequent Substance Use Disorder Onset and Vice Versa. Addict Behav. 2012 Aug;37(8):982-5 Rebecca Kuepper, research psychologist, Jim van Os, professor, visiting professor, Roselind Lieb, professor, Hans-Ulrich Wittchen, professor, Michael Höfler, research statistician, Cécile Henquet, lecturer. Continued cannabis use and risk of incidence and persistence of psychotic symptoms: 10 year follow-up cohort study, BMJ 2011; 342:d738, http://www.bmj.com/content/342/bmj.d738 Wayne Hall & Louisa Degenhardt. Cannabis and the increased incidence and persistence of psychosis. BMJ 2011; 342:d719, http://www.bmj.com/content/342/bmj.d719 Matthew Large; Swapnil Sharma; Michael T. Compton; Tim Slade; Olav Nielssen. Cannabis Use and Earlier Onset of Psychosis: A Systematic Meta-analysis. Arch Gen Psychiatry. 2011; 68(6):555-561 John McGrath; Joy Welham; James Scott; Daniel Varghese; Louisa Degenhardt; Mohammad Reza Hayatbakhsh; Rosa Alati; Gail M. Williams; William Bor; Jake M. Najman. Association Between Cannabis Use and Psychosis-Related Outcomes Using Sibling Pair Analysis in a Cohort of Young Adults. Arch Gen Psychiatry, 2010; 67(5):440-447 Otten R, Barker ED, Maughan B, Arseneault L, Engels RC., Self-Control and Its Relation to Joint Developmental Trajectories of Cannabis Use and Depressive Mood Symptoms. Drug Alcohol Depend. 2010 Dec 1; 112(3):201-8 Miguel Ruiz-Veguilla, Manuel Gurpegui, Mar¡a Luisa Barrigón, Maite Ferr¡n, Esther Mar¡n, Jos‚ Luis Rubio, Blanca Gutierrez, Antonio Pintor, Jorge Cervilla. Fewer neurological soft signs among first episode psychosis patients with heavy cannabis use. Schizophrenia Research, 2009; 107(2-3): 158, http://www.sciencedirect.com/science/article/pii/S0920996408003472 Barrigón, M. Ruiz-Veguilla, M. Anguita, F.J. Diaz, J. Cervilla, M. Gurpegui. Temporal relationship of cannabis and other illegal drug use with the onset of first-episode non-affective psychosis. Schizophrenia Research, 2008; 98(2):66 Miguel Ruiz-Veguillaa, Jorge A.Cervillab, Maria Luisa Barrigónc, Maite Ferrínd Blanca Gutiérrezb, Estibaliz Gordoc Manuel Anguitac, Antía Brañasc, Jesús Fernández-Logroñoc, Manuel Gurpeguib. Neurodevelopmental markers in different psychopathological dimensions of first episode psychosis: The ESPIGAS Study. European Psychiatry, 2008; 23(8): 533, http://www.sciencedirect.com/science/article/pii/S0924933808015307 Philip R. Szeszko, Delbert G. Robinson, Serge Sevy, Sanjiv Kumra, Claudia I. Rupp, Julia D. Betensky, Todd Lencz, Manzar Ashtari, John M. Kane, Anil K. Malhotra, Handan Gunduz-Bruce, Barbara Napolitano, Robert M. Bilder, Anterior Cingulate Grey-Matter Deficits and Cannabis Use in First-Episode Schizophrenia. The British Journal of Psychiatry, 2007; 190 (3) 230-236 J. van Os, M. Bak, M. Hanssen, R. V. Bijl, R. de Graaf, and H. Verdoux, Cannabis Use and Psychosis: A Longitudinal Population-based Study, Am. J. Epidemiol. (2002) 156 (4): 319-327 Skosnik PD1, Krishnan GP, Aydt EE, Kuhlenshmidt HA, O'Donnell BF, Psychophysiological Evidence of Altered Neural Synchronization in Cannabis Use: Relationship to Schizotypy, Am J Psychiatry, 2006; 163(10):1798-1805 Cheng, M., Report: Using Pot May Heighten Risk of Becoming Psychotic, Associated Press, 26 July 2007 Simon Kearney. Cannabis is “Worst Drug for Psychosis.” The Australian, 21 November 2005 Curtis, John. Study Suggests Marijuana Induces Temporary Schizophrenia-Like Effects. Yale Medicine. Fall/Winter 2004, http://yalemedicine.yale.edu/fw2004/news/rounds/52725. FN3\]. Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health, November, 2016, Chapters One and two and Appendix D pp.65-66 at: https://addiction.surgeongeneral.gov/surgeon-generals-report.pdf \[FN4\]. American Psychiatric Association, 2013 “Position Statement on Marijuana as Medicine,” paragraph 1 found at: https://www.psychiatry.org/home/policy-finder \[FN5\]. https://www.drugabuse.gov/publications/drugfacts/marijuana August 2017 \[FN6\]. Health Effects of Cannabis and Cannabinoids: Current State of Evidence and Recommendations for Research. See: http://nationalacademies.org/hmd/~/media/Files/Report%20Files/2017/Cannabis-Health-Effects/ Cannabis-chapter-highlights.pdf \[FN7\]. https://www.scientificamerican.com/article/link-between-adolescent-pot-smoking-and-psychosis -strengthens/ \[FN8\] http://www.newswise.com/articles/view/685947/?sc=dwtn \[FN9\]. https://www.drugabuse.gov/news-events/news-releases/2017/09/marijuana-use-associated-increa sed-risk-prescription-opioid-misuse-use-disorders \[FN10\] See Why should we care about cannabis? April 28, 2008, http://www.unodc.org/unodc/en/frontpage/why-should-we-care-about-cannabis.html. \[FN11\]https://www.drugabuse.gov/publications/drugfacts/marijuana August 2017 Articles Young adult sequelae of adolescent cannabis use: an integrative analysis Edmund Silins, L John Horwood, George C Patton, David M Fergusson, Craig A Olsson, Delyse M Hutchinson, Elizabeth Spry, for the Cannabis Cohorts Research Consortium* Summary Lancet Psychiatry 2014; Background Debate continues about the consequences of adolescent cannabis use. Existing data are limited in 1: 28693 statistical power to examine rarer outcomes and less common, heavier patterns of cannabis use than those already See Comment page 249 investigated; furthermore, evidence has a piecemeal approach to reporting of young adult sequelae. We aimed to *Other members listed at end of provide a broad picture of the psychosocial sequelae of adolescent cannabis use. paper National Drug and Alcohol Methods We integrated participant-level data from three large, long-running longitudinal studies from Australia and Research Centre (E Silins PhD, New Zealand: the Australian Temperament Project, the Christchurch Health and Development Study, and the D M Hutchinson PhD, Victorian Adolescent Health Cohort Study. We investigated the association between the maximum frequency of Prof L Degenhardt PhD, W Swift PhD, R P Mattick PhD) cannabis use before age 17 years (never, less than monthly, monthly or more, weekly or more, or daily) and seven and National Cannabis developmental outcomes assessed up to age 30 years (high-school completion, attainment of university degree, Prevention and Information cannabis dependence, use of other illicit drugs, suicide attempt, depression, and welfare dependence). The number Centre (Prof J Copeland PhD), of participants varied by outcome (N=2537 to N=3765). UNSW Australia, Sydney, NSW, Australia; Christchurch Health and Development Study, Findings We recorded clear and consistent associations and dose-response relations between the frequency of Department of Psychological adolescent cannabis use and all adverse young adult outcomes. After covariate adjustment, compared with individuals Medicine, University of Otago, who had never used cannabis, those who were daily users before age 17 years had clear reductions in the odds of high- Christchurch, New Zealand (L J Horwood MSc, school completion (adjusted odds ratio 0·37, 95% CI 0·200·66) and degree attainment (0·38, 0·220·66), and Prof D M Fergusson PhD); Centre substantially increased odds of later cannabis dependence (17·95, 9·4434·12), use of other illicit drugs for Adolescent Health, Murdoch (7·80, 4·4613·63), and suicide attempt (6·83, 2·0422·90). Childrens Research Institute, Royal Childrens Hospital, Melbourne, VIC, Australia Interpretation Adverse sequelae of adolescent cannabis use are wide ranging and extend into young adulthood. (Prof G C Patton MD, C A Olsson PhD, E Spry BA, cannabis legislation should be carefully assessed to ensure they reduce adolescent cannabis use and prevent Prof J W Toumbourou PhD, ; School of Psychology, Deakin University, Geelong, VIC, Funding Australian Government National Health and Medical Research Council. Australia (C A Olsson, Prof J W Toumbourou); School of Introduction existing evidence has limitations, including limited Population and Global Health (Prof L Degenhardt) and Marked shifts have taken place in attitudes to cannabis statistical power to examine rarer outcomes and less Department of Paediatrics 1 use. Moves to decriminalise or legalise cannabis use in common, more regular patterns of cannabis use than (Prof G C Patton, C A Olsson, several US states and Latin American countries are a sign - P Letcher PhD) and Psychological 2 Sciences (C A Olsson), University of such changes in public opinion. These shifts have founding; and a tendency to examine only one outcome of Melbourne, Melbourne, VIC, happened while debate continues about the long-term or domain. As such, the picture of adolescent cannabis Australia; Department of Global 3,4 health and social sequelae of adolescent cannabis use. use and its putative health consequences is fractured. We Health, School of Public Health, Additionally, in some countries adolescents are initiating address this issue through the integration of data from University of Washington, 5 Seattle, WA, USA cannabis use earlier than have those in previous years three large, long-running longitudinal studies from 68 (Prof L Degenhardt); National and more adolescents are using cannabis heavily. In Australia and New Zealand: the Australian Temperament Drug Research Institute, Faculty 17 England, 4% of 1115 year olds are past-month cannabis Project (ATP), the Christchurch Health and Develop- of Health Sciences, Curtin 718 users; about 7% of US high-school seniors are daily or ment Study (CHDS), and the Victorian Adolescent University, Perth, WA, Australia 819 (R J Tait PhD); Centre for Research near-daily cannabis users; and in Australia, less than 1% Health Cohort Study (VAHCS). 6 on Ageing Health and Wellbeing, of 1419 year olds use daily and 4% use weekly. This In this integrative meta-analysis, we examined the Australian National University, prevalence is particularly concerning because adolescence long-term sequelae of adolescent cannabis use on Canberra, ACT, Australia (R J Tait) seems to be a vulnerable developmental period for the important domains of wellbeing during the transition to Correspondence to: 9 consequences of cannabis exposure, and evidence Dr Edmund Silins, National Drug and Alcohol Research Centre, suggests that early use of cannabis is associated with measures of cannabis use and each outcome across all 1014 UNSW Australia, Sydney, increased risk of adverse developmental outcomes.cohorts; examine the association between patterns of NSW 2052, Australia use before age 17 years and each outcome in combined e.silins@unsw.edu.au 12,15,16 adolescent cannabis use have clouded debate. The data; and adjust the associations reported for a wide 286 www.thelancet.com/psychiatry Vol 1 September 2014 Articles range of potential confounding factors drawn from All studies obtained data about use of other illicit drugs For more on the ATP see http:// www.aifs.gov.au/atp in the past month or past year from several categories: similar domains across studies spanning individual, family, and peer characteristics and behaviours.inhalants, hallucinogens, ecstasy, amphetamines, methamphetamines, heroin, cocaine, and non-medical Methods use of prescription drugs. We created a dichotomous Design and participants measure for use of other illicit drugs in the past month to the past year by ages 2325 years. Integrative analyses were developed across the ATP, CHDS, and VAHCS (appendix). The analyses were based The CHDS assessed number of suicide attempts at See Online for appendix yearly intervals from ages 17 to 25 years. The VAHCS on data obtained over relevant assessments (appendix) between ages 13 and 30 years. We chose these cohorts used the Beck Self-harm Inventory at seven assessment because they had similar measures of cannabis use and times between ages 16 and 29 years (on average). On the integrated participant-level data rather than using the harm with a serious intention to end life (eg, suicide attempt) were categorised. We created a dichotomous more common meta-analytic approach of combining study-level estimates. This approach had at least three measure of any suicide attempt made between ages 17 advantages: increased sample size and statistical and 25 years for the CHDS and VAHCS. The ATP did not 20,21 precision, the opportunity to include a wide range of assess suicidal behaviour. potential confounding factors, and the ability to provide a broad picture of the health and psychosocial consequences of adolescent cannabis use.The CHDS used the Composite International Diagnostic Interview, the VAHCS used the Clinical Interview Measures and outcomes Schedule, and the ATP used the depression subscale Studies varied in measures used to assess cannabis use from the short-form Depression Anxiety Stress Scale. We created a dichotomous measure of moderate or severe and outcomes, assessment period (eg, past month, past depression in the past week to the past month between 22,23 ages 17 and 25 years. commonalities existed to enable integration of data and development of measures that were consistent across The studies obtained data about present main source of 22,23 studies. We assessed seven outcomes in young people income, including various categories of government support. Because patterns of income are not typically aged between 17 and 30 years, spanning educational 24 attainment, substance use, mental health, and welfare established until the late 20s, we used data from the ATP dependence. The number of participants varied by at ages 2728 years, data from the VAHCS at age 29 years, outcome (from 2537 to 3765 participants). We chose the and data from the CHDS at age 30 years. We created a outcomes on the basis of previous research that established dichotomous measure of present welfare dependence a link between a given outcome and cannabis use, and the (excluding education-related government support) at ages availability of similar outcome measures across the 2730 years. cohorts. Derivation of the harmonised variables is We noted small between-study variations in the summarised below, with additional information in the prevalence of adolescent cannabis use and some appendix. All dichotomous variables were coded as 0 for outcomes (appendix) that might be expected to be present no and 1 for yes.in cohorts obtained from regions of similar cultural and All studies included measures of frequency of cannabis sociodemographic backgrounds. use during mid-adolescence (appendix). We created a We selected potential confounding factors from each study on the basis of previous research suggesting that the cannabis use before age 17 years (with 0 as never, 1 as less variables might be correlated with both cannabis use and than monthly, 2 as monthly or more, 3 as weekly or more, adverse psychosocial outcomes. These confounding factors and 4 as daily).spanned individual background and functioning, and All studies obtained data for the completion of high parental and peer factors. Factors assessed antecedent to school and university degree attainment. We created a cannabis use were included when available. The appendix dichotomous measure of high-school completion, and provides further information about potential confounding university degree attainment, both by age 25 years.factors. All studies included a measure of symptoms of cannabis dependence in the past 12 months. The CHDS Statistical analysis and VAHCS assessed cannabis dependence with the The analysis was based on an integrated dataset that Composite International Diagnostic Interview. The combined participant-level data from the cohorts. The analysis was conducted in four stages. First, we estimated of cannabis dependence. We created a dichotomous association between extent of adolescent cannabis use and measure of cannabis dependence in the past 12 months each outcome with data from each study and from the between ages 17 and 25 years.combined dataset. This analysis examined associations www.thelancet.com/psychiatry Vol 1 September 2014 287 Articles NeverLess than monthlyMonthly or moreWeekly or moreDailyp value* High-school completion ATP833/897 (93%)89/100 (89%)87/102 (85%)24/35 (69%)2/2 (100%)<0·0001 CHDS307/618 (50%)106/276 (38%)18/63 (29%)11/82 (13%)0/7<0·0001 VAHCS851/977 (87%)229/282 (81%)74/90 (82%)85/108 (79%)24/39 (62%)<0·0001 Combined data1991/2492 (80%)424/658 (64%)179/255 (70%)120/225 (53%)26/48 (54%)<0·0001 Degree attainment ATP359/734 (49%)23/82 (28%)22/74 (30%)8/27 (30%)0/3<0·0001 CHDS181/596 (30%)57/257 (22%)11/63 (18%)5/74 (7%)0/7<0·0001 VAHCS415/978 (42%)89/283 (32%)23/90 (26%)13/108 (12%)6/39 (15%)<0·0001 Combined data955/2308 (41%)169/622 (27%)56/227 (25%)26/209 (12%)6/49 (12%)<0·0001 Cannabis dependence ATP25/600 (4%)4/64 (6%)10/55 (18%)11/22 (50%)2/2 (100%)<0·0001 CHDS17/619 (3%)25/276 (9%)12/64 (19%)42/82 (51%)6/7 (86%)<0·0001 VAHCS33/912 (4%)27/259 (10%)17/83 (21%)45/99 (46%)15/33 (46%)<0·0001 Combined data75/2131 (4%)56/599 (9%)39/202 (19%)98/203 (48%)23/42 (55%)<0·0001 Other illicit drug use ATP88/738 (12%)18/82 (22%)17/75 (23%)12/28 (43%)1/3 (33%)<0·0001 CHDS80/596 (13%)83/257 (32%)29/63 46%)31/74 (42%)5/7 (71%)<0·0001 VAHCS41/972 (4%)26/282 (9%)19/89 (21%)31/107 (29%)9/39 (23%)<0·0001 Combined data209/2306 (9%)127/621 (21%)65/227 (29%)74/209 (35%)15/49 (31%)<0·0001 Suicide attempt CHDS26/619 (4%)18/276 (7%)6/64 (9%)13/82 (16%)1/7 (14%)<0·001 VAHCS3/972 (<1%)1/282 (<1%)4/90 (4%)5/107 (5%)1/38 (3%)<0·001 Combined data29/1591 (2%)19/558 (3%)10/154 (7%)18/189 (10%)2/45 (4%)<0·001 Depression ATP47/898 (5%)4/98 (4%)2/102 (2%)2/34 (6%)1/3 (33%)0·661 CHDS80/619 (13%)48/276 (17%)11/64 (17%)20/82 (24%)1/7 (14%)0·006 VAHCS94/1041 (9%)25/288 (9%)13/100 (13%)10/114 (9%)5/39 (13%)0·437 Combined data221/2558 (9%)77/662 (12%)26/266 (10%)32/230 (14%)7/49 (14%)0·032 Welfare dependence ATP26/735 (4%)5/83 (6%)2/75 (3%)0/320/30·491 CHDS41/581 (7%)17/258 (7%)4/61 (7%)16/72 (22%)3/7 (43%)<0·0001 VAHCS77/895 (9%)19/259 (7%)10/90 (11%)9/93 (10%)4/40 (10%)0·578 Combined data144/2211 (7%)41/600 (7%)16/226 (7%)25/197 (13%)7/50 (14%)0·012 Data are n/N (%). ATP=Australian Temperament Project. CHDS=Christchurch Health and Development Study. VAHCS=Victorian Adolescent Health Cohort Study. *p value of behaviour. Assessed at age 2830 years. : Outcomes according to maximum frequency of cannabis use before age 17 years in each study and when data were combined intercepts (B0j) to allow for random sources of between- outcome with data from each study and from the study heterogeneity that were not otherwise represented ratios \[ORs\] and 95% CIs) for the combined data pooled over studies. study and from the combined dataset in which the log odds of each outcome were modelled as a linear function Second, we adjusted for covariates. To account for The models for the combined data were of the form: equation to include these factors. These models were of logit (Yij)=B0j + B1Xij where logit (Yij) was the log odds of the form: logit (Yij)=B0j + B1Xij + a series of covariate factors representing the complete set the outcome Y for individual i in study j (j=1, 2, 3), and Xij was the corresponding frequency of cannabis use for of covariates across all studies j. Overall, we included individual i in study j. The slope parameter for cannabis 53 factors (appendix), but not all these covariates were use (B1) was assumed to be constant across studies. measured by all studies. To address this inconsistency we developed a null covariate model. In this model if a 288 www.thelancet.com/psychiatry Vol 1 September 2014 Articles covariate was not noted for any study, we set this covariate to a value of zero for that study. The advantage of this each outcome. At the individual study level, we recorded approach is that it included all the available data in the analysis. The appendix provides further information except depression and welfare dependence in ATP and about this approach. We obtained estimates of the pooled VAHCS (table 1). For the combined data, all associations adjusted ORs and 95% CIs. association in which increasing frequency of adolescent use on the log odds of each outcome, and a common slope cannabis use was associated with declining rates of high- school completion and degree attainment, and increasing To test these assumptions, we extended the above adjusted risks of cannabis dependence, other illicit drug use, suicide attempt, depression, and welfare dependence. Table 2 and cannabis use over and above the linear model for each level of cannabis use estimated from the regression outcome. In all cases a linear model provided an adequate We adjusted the associations in table 1 for confounding by adding the relevant covariates for each study with the then extended the models to allow the slope parameter for null covariate adjustment approach. We included cannabis use (B1) to vary across studies, and then we did 53 covariate factors from the three studies in the analysis. These covariates spanned individual background and functioning, and measures of parental and peer factors (appendix). Table 2 and 2 show the adjusted ORs For the third stage of the statistical analysis, we did a NeverLess than Monthly Weekly Dailyp valueN monthlyor moreor more Unadjusted odds ratios High-school 10·670·45 0·31 0·21 <0·00013678 biases. To examine the robustness of the null covariate completion(0·620·73)(0·380·54)(0·240·39)(0·150·29) model, we compared results with four alternative estimates Degree 10·63 0·40 0·25 0·16 <0·00013415 of the adjusted ORs, which we derived with a harmonised attainment(0·570·69)(0·330·48)(0·190·33)(0·110·23) covariate approach using a reduced set of covariates Cannabis 12·75 7·58 20·87 57·45 <0·00013177 common to all studies; a covariate score approach in which dependence(2·483·06)(6·149·36)(15·2028·64)(37·6687·64) we used the covariate information in each study to derive an Other illicit 11·82 3·31 6·01 10·93 <0·00013412 drug use(1·661·99)(2·773·94)(4·617·83)(7·6815·55) optimum predictor of each outcome, and the single Suicide 11·72 2·94 5·05 8·66 <0·00012537 predictor score as a covariate in the combined data; a attempt*(1·432·06)(2·044·24)(2·928·74)(4·1718·01) propensity score approach in which we used the covariate Depression11·12 1·26 1·42 1·59 0·0323765 data in each study to derive a prediction model for adolescent (1·011·25)(1·021·56)(1·031·94)(1·042·42) cannabis use, and included the estimated propensity score Welfare 11·17 1·37 1·61 1·88 0·0123284 as a covariate for each study; and a standard meta-analytic dependence(1·041·32)(1·071·75)(1·112·32)(1·153·07) approach in which covariate-adjusted analyses were done Adjusted odds ratios separately for each study, and the study-level result then High-school 10·78 0·61 0·47 0·37 0·0013004 pooled meta-analytically (appendix). Fourth, we investigated completion(0·670·90)(0·450·81)(0·300·73)(0·200·66) the potential for selection bias. We used multiple imputation Degree 10·78 0·62 0·49 0·38 <0·00012834 attainment(0·690·90)(0·470·81)(0·320·73)(0·220·66) to examine the implications of possible selection bias Cannabis 12·06 4·24 8·72 17.95 <0·00012675 attributable to sample attrition and missing data (appendix). dependence(1·752·42)(3·075·84)(5·3914·12)(9·4434.12) We did all analyses with STATA SE (version 13). Other illicit 11·67 2·79 4·67 7·80 <0·00012832 drug use(1·451·92)(2·113·69)(3·077·10)(4·4613·63) Role of the funding source Suicide 11·62 2·61 4·23 6·83 0·0022192 The sponsors of the study had no role in study design, attempt*(1·192·19)(1·434.79)(1·7110.47)(2·0422.90) data collection, data analysis, data interpretation, or Depression11·01 1·01 1·02 1·02 0·9462927 writing of the report. The corresponding author had full (0·851·19)(0·721·42)(0·611·69)(0·522·01) Welfare 11·04 1·08 1·12 1·16 0·7272664 dependence(0·841·28)(0·711·63)(0·602·09)(0·502·66) responsibility for the decision to submit for publication. Data are odds ratios (95% CIs). *Only the Christchurch Health and Development Study and the Victorian Adolescent Results Health Cohort Study assessed suicidal behaviour. Assessed at age 2830 years. Table 1 shows the associations between frequency of : Maximum frequency of cannabis use before age 17 years, and each young adult outcome in cannabis use before age 17 and the outcomes in young combined data, before and after adjustment with the null covariate approach adults in each study and in the combined dataset, and the www.thelancet.com/psychiatry Vol 1 September 2014 289 Articles High-school completion High-school completion 64 16 32 8 16 4 8 4 2 2 1 Adjusted odds ratio 1 Unadjusted odds ratio Degree attainment Degree attainment 16 64 32 8 16 4 8 4 2 2 1 1 Adjusted odds ratio Unadjusted odds ratio Cannabis dependence Cannabis dependence 64 32 16 16 8 8 4 4 2 2 Unadjusted odds ratio Adjusted odds ratio 1 1 Use of other illicit drugs Use of other illicit drugs 64 16 32 8 16 8 4 4 2 2 Unadjusted odds ratio Adjusted odds ratio 1 1 Suicide attempt 64 Suicide attempt 32 16 16 8 8 4 4 2 Unadjusted odds ratio2 1 Adjusted odds ratio 1 Depression : Unadjusted odds 64 Depression ratios (log scale) between 16 32 maximum frequency of 8 16 cannabis use before age 8 17 years and young adult 4 outcomes in combined 4 2 data, compared with 2 Unadjusted odds ratio Adjusted odds ratio individuals who have never 1 1 used cannabis Error bars show 95% CIs. Welfare dependence Welfare dependence 64 16 : Adjusted odds 32 8 ratios (log scale) between 16 maximum frequency of 4 8 cannabis use before age 2 4 17 years and young adult Adjusted odds ratio 2 1 outcomes in combined Unadjusted odds ratio 1 data, compared with individuals who have never Less thanMonthlyWeeklyDaily Less thanMonthlyWeeklyDaily used cannabis monthlyor moreor more monthlyor moreor more Error bars show 95% CIs. 290 www.thelancet.com/psychiatry Vol 1 September 2014 Articles between the extent of cannabis use and each outcome in associations were resilient to control for potential the combined data. After adjustment, the associations for confounding factors present before and during depression and welfare dependence were both non-adolescence. Studies such as ours are limited in their capacity to explain the mechanisms behind such associations, although some research has suggested that The estimates for adjusted ORs suggested that individuals 9 who were daily users before age 17 years had odds of development; alternatively, cannabis use in adolescence high-school completion and degree attainment that were could be a marker of developmental trajectories that place 63% and 62% lower, respectively, than those who had young people at increased risk of adverse psychosocial 25 never used cannabis; furthermore, daily users had odds outcomes. of later cannabis dependence that were 18 times higher, completion, university degree attainment, cannabis odds of use of other illicit drugs that were eight times dependence, and use of other illicit drugs are consistent higher, and odds of suicide attempt that were seven times with previous research investigating the association 10,12,13,23 between early cannabis use and these outcomes. Although the association between cannabis use and high-school completion probably does not arise from a not shown), suggesting that the associations were similar reverse causal association (school dropout leading to 2610 across studies for all outcomes.cannabis use), this possibility remains plausible. The To examine the sensitivity of the results for adjusted ORs in table 2 to choice of model for adjusting covariates, small body of research that supports a more direct 27 we repeated the analyses with four alternative approaches relation between cannabis use and suicidal ideation. to covariate adjustment: harmonised covariate, covariate score, propensity score, and standard meta-analysis associated with adolescent cannabis use after adjustment. these analyses, showing that the results were not dependent on the methodology used to estimate the psychosocial outcomes could plausibly be explained by covariate-adjusted associations. Further analysis using multiple imputation of missing data to control for Panel: Research in context Systematic review were entirely consistent with those of the recorded data We did a review of systematic reviews published since the key 2004 paper by Macleod and (appendix). 15 colleagues. We searched Medline, Global Health, Embase, PsycINFO, and PsycARTICLES with the terms cannabis or marijuana and systematic review for reports about the Discussion welfare dependence), cannabis dependence, use of other illicit drugs, depression, and between the frequency of adolescent cannabis use and all adverse young adult outcomes. These associations had outcomes. Both cross-sectional and longitudinal data link cannabis use with high-school dose-response characteristics across all seven outcomes, 10 dropout, although reverse causality (dropout leading to cannabis use) remains plausible. but two outcomes, associations were resilient to control 11 cohorts link cannabis use with welfare dependence and unemployment. Use of cannabis for the range of potential confounding factors assessed. is associated with development of both cannabis dependence and use of other illicit With control for potential observed confounders, the 12,1312,16 drugs. Although a causal association with depression is in doubt, heavy use in 14 particular, increases the odds of depression. Initial reports also suggest that prenatal 34 individuals who had used cannabis daily before age 35 causal link with suicide. 17 years had odds of high-school completion and degree attainment that were lower than those who had never Interpretation used cannabis before age 17 years, and higher odds of cannabis dependence, use of other illicit drugs, and completing the tasks that mark the transition to adulthood. Prevention or delay of suicide attempt. Results were robust to four alternative approaches to covariate adjustment and imputation of are relevant given the movement in some countries to decriminalise or legalise cannabis missing data. raising a possibility that cannabis might become more accessible to young people. In the rapidly changing political and legislative landscape, protection of adolescents from the possibility of a causal relation. First, we recorded strong associations between adolescent cannabis use and all young adult outcomes investigated. Second, the associations had dose-response characteristics with adolescent development. increasing frequency of adolescent use. Third, most www.thelancet.com/psychiatry Vol 1 September 2014 291 Articles 37 potential confounding factors that had not been lead to earlier onset of use. This hypothesis is concerning 15, 16 adequately controlled for in studies to date. 9 This study has some limitations. First, there was some cannabis between-study variation in the levels of the outcomes, adolescence is associated with increased risk of adverse which could have been shown by variations in estimates of developmental outcomes. In the rapidly changing political and legislative landscape, protection of adolescents from very similar, with Wald tests providing no evidence of important facet of cannabis legislative reforms. Despite criteria for depression in the Australian Temperament increased availability of cannabis (for medical use) in some 38 Study were weaker than those in other studies. However, US states, a study showed no increase in use among irrespective of the way in which depression was measured, the same conclusion holds. Third, although we controlled cannabis legislation should be carefully assessed to ensure for many potential confounding factors, the possibility they reduce adolescent cannabis use and prevent potentially unmeasured or uncontrolled confounding cannot be Contributors 15 GCP, LD, DMF, and LJH conceptualised and designed the study. LJH, completely ruled out. Residual confounding could GCP, CAO, DMF, JWT, CC, and PL acquired the data. ESi, LJH, CAO, attenuate the associations. However, analyses that have ESp, and DMH did the data analysis. All investigators, except PL, contributed to data interpretation. ESi, DMF, GCP, LJH, LD, CAO, confounders suggest that associations between cannabis DMH, and ESp drafted sections of the report. All investigators critically 28,29 use and various outcomes persist. 30 provide a means to control for non- The Cannabis Cohorts Research Consortium Steve Allsop (National Drug Research Institute, Curtin University, Perth, WA, Australia); Wayne Hall (UQ Centre for Clinical Research, University between an exposure variable and an outcome in repeated of Queensland, Brisbane, QLD, Australia); Reza Hayatbakhsh (School of measures data. Fourth, measures were obtained by self- Population Health, University of Queensland, Brisbane, QLD, Australia); report, which might be subject to socially desirable Kerriann Little (Melbourne School of Psychological Sciences and 31 Department of Paediatrics, University of Melbourne, Parkville, VIC, response bias, the extent of which can vary with age. Australia; Murdoch Childrens Research Institute, Royal Childrens Presence of such bias could lead to over-reporting or Hospital, Parkville, VIC, Australia); Jake Najman (School of Social Science, under-reporting of cannabis use. In face-to-face settings University of Queensland, Brisbane, QLD, Australia); Rachel Skinner (as is generally the case for the cohorts in this study) (Sydney University Discipline of Paediatrics and Child Health, Childrens Hospital at Westmead, Sydney, Australia; Telethon Kids Institute, Subiaco, adolescents might be more likely than adults to under- WA, Australia); and Tim Slade (National Drug and Alcohol Research 31 report risk behaviours; however, under-reporting would Centre and Centre for Research Excellence in Mental Health and attenuate any observable associations. Fifth, similarities in Substance Use, UNSW Australia, Sydney, NSW, Australia). the cultural and social context and epidemiology of Declaration of interests cannabis use between Australia and New Zealand suggest We declare no competing interests. that results can be applied to Australasian populations. Acknowledgments Because rates of cannabis use in young people in This study was supported by an Australian Government National Health Australasia are similar to those in other high-income and Medical Research Council Project Grant (number 1009381). The 32,33 National Drug and Alcohol Research Centre and the National Cannabis countries (eg, in the USA, Canada, and the UK), Prevention and Information Centre at UNSW Australia, Sydney, Australia are supported by funding from the Australian Government. GCP is Nevertheless, the social and legislative context of cannabis supported by an National Health and Medical Research Council (NHMRC) 2 use varies between regions, and remains an important senior principal research fellowship (APP1019887). DMH is supported by a vice-chancellors postdoctoral fellowship from the UNSW. LD (APP1041742) and RPM (APP1045318) are each supported by an NHMRC principal This study extends previous research of the link between research fellowship. We thank all individuals and families involved in the adolescent cannabis use and problems later in life by the participating cohorts for their time and invaluable contribution to the study; all collaborators who have contributed to the Australian Temperament integration of data from various sources and the provision Project, especially Ann Sanson, Diana Smart, Margot Prior, and Frank of control for a broader range of covariates than possible in Oberklaid; and Christina OLoughlin, John Carlin, and Helen Romaniuk for their contributions to the Victorian Adolescent Health Cohort. the potential harms of adolescent cannabis use across References several domains. The prevention or delay of cannabis use 1 Benac N, Caldwell A. Marijuana legalization gains support, confounding policymakers. June 29, 2013. http://www. html (accessed Jan 28, 2014). decriminalise or legalise cannabis gathers momentum in a 2 Reuter P. 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Psychol Methods 2009; 14: 15064. www.thelancet.com/psychiatry Vol 1 September 2014 293 Comment Adolescent cannabis use and adverse sequelae in adulthood Present or previous cannabis use is more common in three studies from Australia and New Zealand, clearly individuals with low educational attainment than in shows a doseresponse association between frequency those with higher levels of educational achievement. of cannabis use in adolescence and ability to complete Debate surrounds whether this association is attributable to cannabis use being more frequent in socioeconomic groups that are more likely to have After confounder control, individuals who were daily poor educational attainment, whether cannabis users before age 17 years had reductions in the odds use is actually a marker of an already established of high-school completion (adjusted odds ratio \[OR\] Science Photo Library disadvantageous development, or whether the 0·37, 95% CI 0·200·66) and degree attainment (0·38, See Articles page 286 1 association is a truly causal one.0·220·66) compared with those who had never used In The Lancet Psychiatry, Edmund Silins and colleagues cannabis. Furthermore, cannabis use was associated 2 integrative meta-analysis assesses the long-term with increased risk of suicide attempt (adjusted OR 6·83, psycho social sequelae of adolescent cannabis use. The 95% CI 2·0422·90) and, unsurprisingly, later cannabis report, which is based on participant-level data from dependence (17·95, 9·4434·12) and use of other illicit www.thelancet.com/psychiatry Vol 1 September 2014 249 Comment drugs (7·80, 4·4613·63). The participation rate in the study is impressive, the attrition rates are modest, and in adolescents than in adults. the number of confounding factors, assessed across Cannabis use in adolescence has also been associated 7 cohorts, is overwhelming and covers a broad range of with increased risk of psychosis in adulthood. Cannabis 8 use is associated with earlier onset of psychosis, and Persistent cannabis use has adverse effects, such in patients with cannabis use and psychosis, risk of as low energy and initiative, and impairment of continuous psychotic symptoms is higher in those who 9 cognitive functions, and these factors are likely to continue to use cannabis than in those who stop . mediate the harmful effect of cannabis on educational The convincing results presented by Silins and 2 attainment. Findings from randomised clinical colleagues are very valuable and highly appropriate trials show a negative short-term effect of cannabis at a time when several American states and countries intake compared with placebo on cognitive function in Latin America and Europe have decriminalised or during, and in the hours following, intoxication. legalised cannabis and allow unrestricted marketing Compared with placebo, dronabinol impaired working of various formulations of the drug. Such changes 3 memory and verbal fluency in a trial involving in legislation will probably be followed by decreased 4 22 healthy volunteers. In another trial with 30 healthy prices and increased use, which will lead to more young participants, Morrison and colleagues showed that working memory and executive functions were social and personal maturation, and will increase the reduced by 1020% in participants randomised to risk of psychosis. receive dronabinol.Youth is a very vulnerable period in life. Socially, A randomised clinical trial that exposes some young people need to develop and mature, and young people to cannabis in various doses for a to prepare themselves to meet demands in their long term and compares them with other young people given placebo will never be done. Therefore, findings from naturalistic experiments will be relied partners and friends. Cannabis use, especially frequent on to obtain knowledge about whether the harmful uses, impairs this development and reduces the likeli- effect on cognitive function is temporary. Increasing hood that a young person will be able to establish a evidence shows that brain development during satisfactory adult life. adolescence can be harmed by frequent cannabis use, and cognitive functions can be permanently reduced. Merete Nordentoft 5 University of Copenhagen, Mental Health Center Copenhagen, In the Dunedin birth cohort cognitive function Mental Health Services in the Capital Region of Denmark, was examined at age 13 years and again at age Copenhagen 2400, Denmark 38 years. Continuous cannabis use was associated mn@dadlnet.nk with neuropsychological decline across all domains I declare no competing interests. of cognitive functioning, and more persistent use 1 Macleod J, Oakes R, Copello A, et al. Psychological and social sequelae of cannabis and other illicit drug use by young people: a systematic review of was associated more severe decline. Additionally, longitudinal, general population studies. Lancet 2004; 363: 157988. adolescent-onset cannabis users were more impaired 2 Silins E, Horwood LJ, Patton GC, for the Cannabis Cohorts Research Consortium. Young adult sequelae of adolescent cannabis use: than adult-onset users and neuropsychological an integrative meta-analysis. Lancet Psychiatry 2014; 1: 28693. functioning in adolescent-onset users was not fully 3 DSouza DC, Perry E, Macdougall L, et al. The psychotomimetic effects of intravenous delta-9-tetrahydrocannabinol in healthy individuals: restored after cessation. The investigators concluded implications for psychosis. Neuropsychopharmacology 2004; 29: 155872. that their findings were suggestive of a neurotoxic 4 effect of cannabis on the adolescent brain. intravenous Delta9-tetrahydrocannabinol on psychosis, mood and 6 cognitive functioning. Psychol Med 2009; 39: 160716. In a review, Schweinsburg and colleagues concluded 5 Meier MH, Caspi A, Ambler A, et al. Persistent cannabis users show that studies of adolescents who were heavy marijuana neuropsychological decline from childhood to midlife. Proc Natl Acad Sci USA 2012; 109: E265764. 6 least 6 weeks after discontinuation, particularly in the neurocognitive functioning in adolescents. Curr Drug Abuse Rev 2008; 1: 99111. domains of learning, memory, and working memory. 250 www.thelancet.com/psychiatry Vol 1 September 2014