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A survey of Maryland medical cannabis patients indicates an increase in risky behaviors involving cannabis after “the pivotal transition” to adult-use legalization in 2023, according to a report prepared for the Maryland Cannabis Administration.
More respondents reported driving under the influence of cannabis and consuming cannabis while pregnant and/or breastfeeding in 2023 than did in a survey the year before, among other findings.
The nature of the two cross-sectional surveys, however, does not permit conclusions to be drawn, as the same respondents were not followed from year to year.
“The report seems to suggest that recreational legalization in Maryland is the factor that is causing changes from 2022 to 2023,” said Johannes Thrul, an associate professor at the Johns Hopkins Bloomberg School of Public Health who researches substance use. “You’re just hitting different individuals who have a slightly different response behavior.”
While noting that causal relationships cannot be defined from cross-sectional surveys, the authors state that the 2023 report “details the extent to which key measures of interest changed with expanded legalization, including patterns of use, perceptions of risk and benefit, and the occurrence of high-risk behaviors related to cannabis use.”
Tia Lewis, spokesperson for the Maryland Cannabis Administration, formerly the Maryland Medical Cannabis Commission, said in an email that cross-sectional studies can be done more rapidly and at a lower cost than longitudinal studies, which examine a group of individuals over time. Cross-sectional studies also facilitate anonymous data collection, Lewis said.
In total, roughly 30,000 medical cannabis patients took part in the 2022 and 2023 surveys, which were conducted by Massachusetts-based Cannabis Public Policy Consulting. The second survey was conducted over five days in September and October 2023. Adult-use legalization took effect in Maryland in July 2023.
The percentage of respondents who reported that they had driven under the influence of cannabis at least once in the previous month increased from 18% to 39% year over year, according to the latest report.
Thrul said changing social norms around cannabis, not Maryland’s adult-use legalization, could be responsible for the increase, with people becoming less shy about admitting that they drive under the influence.
“These are long-term trends that we have observed in the U.S. broadly, that cannabis use has become and is becoming more and more acceptable,” he said.
Thrul was also unwilling to pin the increase in cannabis use during pregnancy and/or breastfeeding on Maryland’s adult-use legalization. Seventy-five percent of the 125 pregnant and/or breastfeeding respondents in 2023 said they had consumed cannabis in the previous month, up from 56% of the 106 respondents in the 2022 survey.
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“I just don’t think that we can make the claim that this is a change due to legalization from one year to the next,” Thrul said, adding that consuming cannabis during pregnancy or breastfeeding was ill advised.
Alexander Dix, a pharmacist and the clinical director of the KIP cannabis dispensary in Cockeysville, said that 125 pregnant and/or breastfeeding people was a very small sample size.
“Usually when you conduct scientific studies you need a large enough population to be able to determine if something is statistically significant or not,” he said. “While (the study) does show some data that might concern some people, I don’t think it’s really enough to say that there’s any kind of public health concern happening.”
The 2023 survey also asked about cannabis use in conjunction with other substances, including alcohol, antidepressants and opioids, among others.
Nearly one-fifth of respondents consumed cannabis to reduce, replace or stop the use of alcohol, while almost 16% sought to alter their use of antidepressants. Roughly 13% used cannabis to alter their use of opioids.
“It is very common for people to use cannabis and opioids at the same time while reducing their opioid doses so that they experience less of the side effects and less of the addictive potential but still achieve the same level of pain relief,” Dix said, explaining that cannabis and opioids have a synergistic effect.
The 2023 report also noted that one-third of respondents met the criteria for Cannabis Use Disorder (CUD), which was associated with higher frequency of use, higher THC dose and more days of driving under the influence of cannabis per month. However, the report noted that there were “unanswered questions” in the research literature about the suitability of the CUD test for medical cannabis patients.
Thrul said cannabis is addictive when used frequently over an extended period, but he did not dismiss its potential.
“Cannabis is complex and there’s certainly potential for benefits and harms,” said Thrul, who, with colleagues, is about to launch a national cannabis study.
The report’s authors concluded that future MCA efforts should address cannabis patients’ perceptions of risk and the rise in negative outcomes indicated in the 2023 survey.
