Recent users of CBD, e-cigarettes, and cigarettes were more likely to have an abnormal mental health screen by PHQ-4 compared to nonusers. CBD users were more likely than nonusers to have a severe score on the PHQ-4, report depressive symptoms on the PHQ-4, but there was no difference in anxiety symptoms. E-cigarette and cigarette users were more likely to have a mild, moderate, and severe score on the PHQ-4 than nonusers, as well as, more likely to report anxiety and depressive symptoms on the PHQ-4. There was no significant difference found in mental health between users and nonusers of marijuana. There were differences in CFTR modulator use between recent users and nonusers of substances. Recent marijuana users were 1.92 times more likely to report being on CFTR modulators in univariate logistic regression and 2.45 times more likely in the multivariate logistic model adjusted for age, gender, race, ethnicity, ppFEV1, and PHQ-4 . Recent users of e-cigarettes were 4.07 times more likely to report taking CFTR modulators in the univariate logistic regression, and 2.92 times more likely in the multivariate analysis adjusted for age, gender, race, ethnicity, ppFEV1, and PHQ-4 . Although the differences for both marijuana and e-cigarettes did not reach statistical significance, indoor grow racks the confidence intervals exclude any meaningful differences of lower CFTR modulator use inrecent substance users compared to nonusers. There were no significant differences in recent cigarette or CBD users by CFTR modulator use in logistic regressions .
Substance users reported various effects, some positive and some negative. Both marijuana and CBD users reported concentration difficulties and energy changes; CBD users mainly noted an improvement in energy, while marijuana users noted increased drowsiness. Appetite changes were frequently reported; many marijuana users reported improved appetite, while many e-cigarette and cigarette users reported decreased appetite. E-cigarette users frequently experience nausea and vomiting. Cough and shortness of breath were often reported by e-cigarette and cigarette users. Despite reporting various effects of substance use, the majority of recent users reported no weight or lung function changes related to their substance use.In this cross-sectional study of marijuana, CBD, e-cigarette, and cigarette use in teenagers and adults with CF, we found that a substantial proportion of pwCF engaged in experimentation with at least one of these substances over their lifetime. Surprisingly, approximately one-quarter of subjects surveyed reported recently using either marijuana, CBD, e-cigarettes, or cigarettes, with marijuana and e-cigarettes being the most commonly used substance. We found notable differences in the rates of marijuana, e-cigarette, and cigarette usage in pwCF compared to prior studies. Our study reports the rates of CBD usage in pwCF for the first time, showing a prevalence of 22% among subjects in this study. In a crosssectional study of teenagers and young adults with CF, Hamberger and colleagues found that 27.4% of subjects used marijuana, 15.2% used e-cigarettes and 25.7% used cigarettes in their lifetime. However, their study did not investigate current or recent usage. In our study, we found a much higher lifetime use of marijuana , e-cigarettes , and cigarettes . We also found a higher rate of usage among recent users than other studies with 29.4% of subjects reporting marijuana use in the last year. In contrast, a cross-sectional study of six CF centers found a lower prevalence, with 16.5% reporting marijuana use in their lifetime and 15.4% in the last year.
This study by Stephen and colleagues focused on usage and attitudes towards medical marijuana in pwCF, while our study focused on all use of marijuana in pwCF. The higher rate of use of marijuana likely reflected the changing legalization of marijuana in the United States in recent years. The higher usage rates of the other substances in our study also reflected broader trends in substance use in the United States; our data is consistent with national data from the general US population, showing that 43% of Americans used marijuana, 19% vaped nicotine, 22% vaped marijuana, and 19% used cigarettes in the last year.2Our study gathered important information about characteristics of pwCF who use substances that have not been previously reported. Substance use was higher across all substances among pwCF who were college-educated, aged 26–39 years old, or Black. While male pwCF were more likely to be recent users of CBD, e-cigarettes, and cigarettes, pwCF whoare female or have other gender identities were more likely to use marijuana. Interestingly, recent users of e-cigarettes and cigarettes were less likely to have normal or severe lung function compared to nonusers; Recent use of e-cigarettes and cigarettes was higher in those with mild or moderate lung disease. There was no significant difference in pulmonary function by usage of marijuana and CBD. To explain these findings, we hypothesize that individuals with poorer lung function have increased health care interactions and therefore may be better educated on the risks of vaping, while those with higher lung function may be more health conscious and exhibit higher health awareness. It is important to note that while our study identified important demographic and health characteristics associated with various substance use in pwCF, the prevalence of substance use overall was high in our study. Our findings confirmed the importance of incorporating substance use discussions and education into routine care regardless of demographic, health, or socioeconomic status.We observed a high usage rate of marijuana vaporization and smoking, and a surprisingly high utilization of in halational methods for CBD. CBD is often less frequently asked about among CF healthcare teams, and many CF care providers feel unprepared to answer questions regarding CBD. Given the potential for worsening lung disease and respiratory symptoms, it is vital to routinely discuss both marijuana and CBD usage, counsel, and discuss modalities.
Inhaling any substance can exacerbate airway inflammation and hasten lung damage, especially in those already afflicted with underlying lung disease. Furthermore, alternative forms of marijuana and CBD, such as edibles and topical solutions, present challenges due to their higher cost, limited accessibility, and potential interactions with CFTR modulator drugs, thereby potentially complicating their usage as an alternative to CF management strategies.With significant improvements in lung and overall health with highly effective modulator therapy, we investigated the rate of use of substances in pwCF on CFTR modulators. We found that e-cigarette and marijuana use were more than two times higher in those on CFTR modulators than those not on CFTR modulators. Although these associations did not reach statistical significance after adjusting for other factors, these associations are likely clinically meaningful as there was a strongly positive trend of the odds ratio, and essentially rule out that pwCF on CFTR modulators have lower substance use. There were no significant differences in CBD and cigarette use between those on and not on CFTR modulators. The increased trend in e-cigarette and marijuana use among those on CFTR modulators poses significant concerns as there is ample data on lung injuries associated with e-cigarettes. Tobacco smoke exposure can cause impairment in CFTR functional expression, which may mitigate the benefit of CFTR modulators. The impact of marijuana smoke exposure on CFTR expression has not been studied. With social influence and increased access to these agents, it is critical that drug use assessment and education be implemented in routine CF care, especially as pwCF live longer in the era of effective modulator therapy to prevent adverse outcomes from substance use.Mental health continues to be a major concern in pwCF. In our study, many subjects had abnormal mental health screens; except for marijuana, poor mental health was associated with recent substance use. Notably, growing benches recent e-cigarette and cigarette users were associated with anxiety and depression, while recent CBD users were associated with depressive symptoms. Many reported using substances to minimize the impact of their illness and improve their mental well-being, often to address anxiety, depression, and sleep issues. Recent users frequently used CBD and marijuana as mood stabilizers; however, hyper awareness and anxiety were also reported as side effects. Approximately half of subjects who quit marijuana reported wanting to avoid psychoactive effects. Although recent users noted worsening mental health with e-cigarettes and cigarettes and a desire to stop using, quitting rates were lower when compared to marijuana and CBD, likely due to the highly addictive nature of nicotine.17 While the causal relationship between substance use and mental health remains uncertain, it is crucial to recognize that some substances can exacerbate pre-existing mental health issues frequently observed in patients with chronic diseases. It is also worth noting that some patients may experience neurocognitive, mood, and anxiety changes after initiating CFTR modulator therapy. Our study did not explore the relationship between modulator therapy initiation, substance use timing and mood which may be a confounding factor.Similar to findings reported by Stephen and colleagues, we also found that approximately half of the subjects who had never used would try marijuana or CBD if given the opportunity or if marijuana was legal. This can indicate a probable increase in substance usage among the CF community as societal stigma around marijuana decreases and legality continues to shift. In addition, we found that many pwCF used substances due to the influence of friends and family and seeking a sense of normalcy, as seen in a prior study. As pwCF are leading longer lives with fewer significant health disruptions due to CFTR modulators, substance use prevalence may increase over time. There is a great need to expand the current knowledge of and guidance regarding marijuana and CBD use in the CF patient population. Further research is warranted to counsel pwCF accurately, as many report experiencing therapeutic benefits. With the advancements in therapies that enhance the quality of life and increase life expectancy, coupled with evolving legal landscapes, pwCF will have more opportunities to explore these substances than previous generations. In this study, we have identified several factors with respect to substance use in pwCF that merit further consideration in CF routine patient care and future research. Most importantly, CF care providers must screen for substance use starting in the patient’s early teenage years. Second, CF care providers should feel comfortable addressing the topics of marijuana, CBD, e-cigarettes, and cigarette use and potential risks with patients and families. Finally, more studies are needed to understand potential interactions between these substances, especially marijuana and CBD and the concomitant use of CFTR modulators.There are a few limitations to our study. First, we relied on self-reported rather than clinical data, so the associations of substance use with health outcomes and CFTR modulators may be under- or over-reported. Second, the survey was administered through online channels utilizing social media platforms, a method susceptible to infiltration of fraudulent responses. We addressed this by including internal validity questions and using Completely Automated Public Turing test to tell Computers and Humans Apart feature. We carefully reviewed the validity questions and removed suspected automated responses by bots from the study. Third, subjects recruited via social media may represent pwCF who have an interest in these substances, which would potentially overestimate the rate of use, however, we found that it was not significantly skewed toward recent use relative to nonuse. The survey was also not translated into Spanish, limiting the participation of a subset of potential subjects, and our findings’ generalizability; therefore, our results should not preclude discussions around substance use in all pwCF. With its roots in international treaties signed during the League of Nations Era, the transnational legal order of cannabis prohibition represents one of the most sustained efforts to develop internationally applicable standards for governing illicit markets. The vast majority of United Nations member states are now parties to the three major international drug conventions, which require criminalizing the production, distribution, and use of cannabis. Over the past decades, the cannabis prohibition TLO has come to encompass an extensive array of legal instruments for monitoring implementation efforts, disseminating information on the activities of drug trafficking networks, and facilitating cooperation among national police forces. However, despite the extensive institutionalization of this TLO, cannabis remains the most widely used illegal drug in the world. The 2018 World Drug Report estimates that at least 192 million people aged 15–64 had used cannabis in the preceding year. With the percentage of adults reporting cannabis use in North American and European countries far exceeding the international average, cannabis use has become integrated into mainstream culture in a large number of countries.