Findings from a Survey of Medical Marijuana Users in Los Angeles County

1. Findings from a Survey of Medical Marijuana Users in Los Angeles County Christine E. Grella, Ph.D. UCLA Integrated Substance Abuse Programs June 8, 2013 Supported by LA County Department of Public Health, Substance Abuse Prevention and Control (SAPC)

2. Brief History of Medical Marijuana Policy • 1996: Prop 215, the Compassionate Use Act, was passed in California allowing adults with a doctor's recommendation to possess and cultivate marijuana for personal medicinal use – the first in the U.S. • The state law is in conflict with Federal regulations because marijuana is classified as a Schedule 1 substance (1970 Federal Controlled Substances Act) • Subsequent legislative changes to the law and judicial decisions resulted in the growth of an extensive system of collective and cooperative dispensaries. • 2007: LA passed a moratorium on licensing new dispensaries (caped at 187); yet estimates were that unregulated dispensaries numbered in the thousands.

3. Medical Marijuana Dispensaries in Los Angeles County

4. Brief History of Medical Marijuana Policy • 2009: The City Council imposed stricter regulations for obtaining land use permits for dispensaries, yet this ordinance was overturned and numerous challenges have been filed to the legality of efforts to regulate the dispensaries. • 2010: A ballot initiative in California to legalize sales of marijuana to adults failed. • 2011: The governor authorized a reduction in criminal sanctions for possession of small amounts of marijuana for personal use.

5. Brief History of Medical Marijuana Policy • 2011-12: The U.S. Attorney General began an aggressive process of shutting down selected dispensaries, stating that they were “significant commercial operations” that were de facto drug distribution centers in violation of Federal law. • At present: MM is legal in 18 states plus the District of Columbia and marijuana distribution is legal Colorado and Washington. • U.S. Attorney General will issue a ruling on how they intend to treat Colorado and Washington laws. • In May, Calif. Supreme Court upheld a lower court ruling that municipalities may ban dispensaries (since there is no way to “regulate” an illegal entity). • On May 21, Proposition D passed in LA, which restricts dispensaries to the original 135 and increases taxes.

6. Epidemiological study: who are users of medical marijuana?

7. Background • There is a lack of scientific data on the individuals who use MM • Critical questions pertaining to important public health issues, such as: • Reasons for using MM and patterns of use • How does access to the dispensaries influence initiation and patterns of use • Do consumers distribute marijuana obtained from the dispensaries to others

8. Background • No clear distinction between medical and recreational use of marijuana in the literature. • It is unclear whether individuals who use MM perceive its use to be primarily “medicinal” (i.e., to treat specific health problems or to alleviate side effects of medication or other treatments), primarily “recreational” or non-therapeutic (i.e., to alter mood, to get “high,” to socialize), or as both. • Nor is there a good understanding of the relationships among dose and frequency of use, clinical diagnosis of dependence, and health outcomes and social functioning.

9. Two phase study supported by SAPC • Focus groups with 30 MM consumers • Survey of MM users using a cluster-based sample of dispensaries • Qualitative observations of the dispensaries

10. Focus Group Methods (N =30) • Individuals were recruited by posting fliers at dispensaries • Each group focused on different region of the county (e.g., Hollywood, Venice Beach, Westside) • 5 groups were held at ISAP in the evening • Participants were paid $50 for participating • Food was provided!

11. Focus Group Findings (N = 30) • Nearly all participants had a history of marijuana use prior to receiving their MM recommendation, usually initiating use in adolescence and often with family. • My mother has been smoking cannabis since she was 14 years old. My mom would smoke in the house . . . she never talked about it, it seemed like school wanted to make it worse than it actually was and I didn’t actually feel there was anything wrong with it. • I’ve been smoking over 40 years, my son probably picked it up behind me. • My parents smoked when I was a kid and, yes, I was exposed to it at a very young age and I didn’t start smoking until much later. . . I avoided [it] for a long time.

12. Focus Group Findings • Some individuals had ceased marijuana use for a period, only to resume use at a later date. Others had used continuously, but had recognized [or redefined] its medical benefits after years of use: • [As an adolescent, I used marijuana] with friends, going out to a concert or some event, party. But recently . . . I got MM for anxiety and depression and now it’s not necessarily recreational it’s more for relaxation and to deal with the anxiety and depression . . . I smoke it at home a lot by myself.

13. Focus Group Findings • Most reported sleep problems, anxiety, depression, or chronic pain as their primary reason for use, although some had serious chronic health problems related to a serious accident, illness, or mental disorder. • I’ve been smoking weed since I was ten years old or something, but medicinally I got it for chronic pain. • I originally started using when I was 9 years old and that was just because of like friends and stuff, they were using it . . . as I started getting older, I started realizing more things that I needed it for because of back problems, sleeping problems, I’ve always had insomnia as a little kid too. • As a teenager I probably was self-medicating through marijuana as an alleviant for the conditions I was experiencing because I really wasn’t comfortable with pharmaceuticals.

14. Focus Group Findings • Participants preferred MM over prescription meds: • I was taking all the [Rx] medications, I was shaking constantly and I was taking, you’re not going to believe this, [but] I was taking a medication [for] a side effect to counteract a side effect. • I tried prescription medication . . . and I don’t like the way that they make me feel when I wake up, I feel groggy. • Although I was previously smoking marijuana before I started going to dispensaries, last year, after a car accident, I had a lot of back problems. • I was looking for something to ease the pain that wasn’t ‘crazy pills.’ I thought it helped a lot - I was never a person that was really into taking the pain pills that they would offer you like Vicodin . . . I thought it was the best for me.

15. Focus Group Findings • Participants felt that dispensaries counteract the highly stigmatized image of marijuana users that is pervasive in society, stemming from years of fear-based prevention messages. • They appreciated being treated with respect and compassion for their problems and they identified as “patients.” • They strongly preferred the safety of obtaining MM from the dispensaries rather than “from a dealer” or “on the streets,” and supported regulating MM to ensure product safety.

16. Focus Group Findings • Participants varied in whether they perceived any problems related to MM use. • I would think, wow, am I a drug addict, even though it’s just marijuana and that’s bothered me . . . There’s plenty of times where I thought, well I’m using it just like a crutch, I just kind of like regular[ly] use, not just the accident, just basically, I just like to smoke. • I am still dealing with the addiction issue because I smoke everyday. I’m habitual and I am aware that when I need to stop, I stop. But it is really easy not to stop . . . it’s around me everywhere all the time. • In high school it was around, I just chose not to do it . . . I know that if I had smoked in high school it honestly would have affected my ability to perform academically and [now] I see it has affected my brother. • I see what it can do basically at a young age, just like alcohol. It’s just some things you shouldn’t do before you’re mature enough to handle the effects of what it will do to you.

17. Survey Methods • Lists of MM dispensaries were compiled (e.g., city attorney’s list, web sites, official registered sites, trade publications) and cross-checked • MM dispensaries were randomly sampled within Service Area (SA) • Number of surveys to be completed was proportionate to the number of dispensaries documented in that SA; goal = 200 surveys • Brief survey (5-8 min) was designed in collaboration with SAPC

18. Methods • Survey teams approached the selected dispensaries and requested their participation in the survey • 4 SA’s (Antelope Valley, South LA, East LA, San Gabriel Valley) had very low density of dispensaries and were dropped from the sampling frame • Surveys were completed in: Westside, South Bay, Downtown/Hollywood, and San Fernando Valley

19. Methods • Days and times of site visits to dispensaries were varied to maximize sampling variability. • 182 client and 29 staff surveys were completed • 65 refusals to participate, mostly younger males who said they were “too busy” • Individuals were paid with a $10 voucher of their choice for participating • Descriptive analyses conducted by age and other subject characteristics

20. Medical Marijuana Dispensaries: Survey Participation (N=40)

21. Survey Findings: Socio-demographics(N = 182) • 74% were male – consistent with population data • Age range: 17 - 63, Mean = 28.4 (sd = 5.3) • Race/ethnicity • 44% White • 26% Hispanic • 13% African American • 6% Asian/Pacific Islander • 11% Other • Most had some college education; 32% were currently students • 45% were employed full-time and 24% part-time

22. History of Marijuana Use • Age of first marijuana use: range = 8 – 42; median = 15 • Ave duration of MM use was about 2.5 years. • Primary condition for MM use was evenly split between physical health and mental health conditions; no difference by age group. • Nearly all (91%) believed that use of MM has helped them “very much.”

23. Recent Use of Other Substances • 21% used illicit drugs in past 30 days • 46% met criteria for risky alcohol use on at least one day in past 30 • 5 or more drinks in one sitting (for men); 4 or more (for women) • 44% smoked cigarettes • Few respondents had ever received drug treatment (n=5) or believed they needed it (n=2)

24. Other Substance Use in Past 30 Days

25. MM Use Patterns • Ave no. of dispensaries visit/mo = 2.7 • Ave no. of days visit dispensary/mo = 12.2; median = 9.5 • Ave no. of days use MM/mo = 23.8; range = 3 – 31; median = 29

26. What Factors are Most Important in Deciding Which Dispensary to Use

27. Other Sources Where they Obtain Marijuana

28. How many of your friends use MJ? • 16% have bought marijuana at a dispensary for friends or family who do not have a MM recommendation

29. Use of MM in Place of Other Drugs

30. Psychological Symptoms in Past Year

31. Comparisons by Age • Younger individuals (< 30) were more likely to be male and Hispanic • Younger individuals had higher rates of tobacco use (51% vs. 33%, p < .05), but no difference in risky alcohol use • Older individuals were more likely to report psychiatric symptoms (76% vs. 59%, p < .05)

32. Patterns of MM Use by Age • Younger users: • Visit dispensaries on more days/month: 14.1 vs. 8.8 days (p < .01) • Go to more dispensaries per month: 2.95 vs. 2.2 (p = .08) • Are more likely to use MM 4 or more times/day: 23.5% vs. 14.5% • Are more likely to use with others and to have friends who use MM

33. Do you primarily use MM alone, with others, or both? P < .001

34. How many of your friends use MJ? P < .001

35. Summary • Distinct profiles of MM users by age: • Younger users have higher rates of tobacco use, visit dispensaries more often, use on more days, use more frequently, and are more likely to have friends who use marijuana and to use with others – but are no more likely to divert MM to others. • Older users rate their health more poorly overall and have more psychiatric symptoms. • Yet overall few (< 10%) rated their health as “fair” or “poor” • Over half use MM in place of prescription drugs

36. Conclusions • There was no indication that individuals initiated marijuana use by obtaining it from the dispensaries • Most obtained marijuana from other sources (in addition to the dispensaries) • Most affiliate with others who also use MM – although use among younger adults is more socially embedded • Location/convenience was most often cited reason for selecting a given dispensary, although individuals typically went to two or more dispensaries per month