While older Black adults had a higher prevalence of cannabis use than other races and ethnicities in the past,this gap considerably narrowed. Still, limited information exists on cannabis use patterns among older Black adults and specific risk factors that could influence cannabis-related ED visits. This must be a focus for future studies, given the high ED rates found in this study. Our study is consistent with the literature that shows an increase in acute medical services rendered related to cannabis use nationally and in other states over the past two decades.The few studies focused on older adults examined how cannabis use may be related to injuries or trauma that necessitates ED use and not overall epidemiological patterns of cannabis-related ED visits. Our findings, in a state with both legalized medical and recreational cannabis use since 2016, show that older adults experienced significant increases in cannabis-related ED visits. Interestingly, the ED rate appeared to increase sharply between 2013 and 2017, but then the rate of increase levels off in 2017 after the implementation of Proposition 64. Therefore, the availability of recreational cannabis does not appear to correlate with a higher rate of increase in cannabis-related ED visits among older people. However, high ED rates among older adults with higher comorbidity are concerning as cannabis has been associated with acute cardiac, respiratory, and psychiatric effects.It is important to note that our study also found a higher relative increase in cannabis-related ED visits among older adults with the lowest comorbidity,4×4 grow tray emphasizing that all older adults may be at risk regardless of the presence of chronic diseases.
All older adults, therefore, should be asked about cannabis use and have discussions about its use with their clinicians. This study has several important limitations. First, we acknowledge that our study includes the transition from ICD-9 to ICD-10, which is a limitation for any trend analysis. Given that the current ICD-10 has more specific cannabis-related diagnoses, this may have increased rates of cannabis-related ED visits from 2015 to 2016. Despite this limitation, we felt it was important to include all 15 years to demonstrate changes in the rate of cannabis-related ED visits among all older populations. Furthermore, we utilized several strategies to address this, including keeping cannabis-related diagnoses consistent during the transition and not including ICD-10 codes for the category of “adverse effects of cannabis,” which did not have comparable diagnoses codes in ICD-9. Our sensitivity analysis showed that this cannabis-related category would have made up <2% of the overall cannabis-related ED visit rate, while poisonings or adverse effects of lysergide and psychodysleptics accounted for <0.1%. Additionally, we cannot differentiate the type of cannabis involved, route of use, or distinguish between medical versus recreational use. This study also captured ED visits and not individuals. Further, there is heterogeneity in coding among clinicians, which is inherent in all studies using administrative data. This may also include a reporting bias, as clinicians may have been more aware of the possible role of cannabis in ED presentations later in the study period. Finally, our study is limited to the state of California and does not include Veterans Administration facilities, and results from this study are not generalizable nationally or to other states. The need for acute medical care is an adverse effect of cannabis use among older adults and is increasing sharply in California. Given the higher risk for adverse effects related to cannabis,all older adults, regardless of health status, should be regularly asked about their use of cannabis and assessed for problematic use.
Despite the currently limited evidence to help balance the risks and benefits of cannabis use,clinicians should educate and discuss cannabis use in the context of health as part of routine medical care for older adults. This is also important for patients immediately after an acute episode in the ED, so they are aware that cannabis may have contributed to their visit. While there is great interest among older adults in using cannabis to treat chronic symptoms,discussions about the potential health-related harms of cannabis should be had, especially among older adults with multimorbidity.With the legalization of cannabis for recreational use in 2017 , the Government of California embarked on an unprecedented, multi-agency initiative to regulate the production of an agricultural crop worth up to $20 billion per annum , the largest cash crop in California . The state initially projected $1 billion in tax revenue from cannabis sales following legalization for recreational use . Building off recent regulations for medical cannabis production , the state created a new licensing system for growers producing cannabis for recreational use, which like medical cannabis, would be distributed legally to the public through state-licensed dispensaries. The CalCannabis Division of the California Department of Food and Agriculture issues cannabis cultivation licenses. To cultivate for legal markets for recreational use, cannabis growers are required to get a CDFA cultivation license and comply with State Water Resources Control Board , California Department of Fish and Wildlife and Department of Pesticide Regulation requirements; all county and local regulations, including land use ordinances; and any additional mitigation stipulations necessary to obtain California Environmental Quality Act approval . Depending on farm location and cultivation practices, growers may also require road development permits, water diversion permits, wastewater discharge permits and CDFW lake and streambed alteration agreements.
CDFA has the authority to issue renewable annual cultivation licenses; it can also issue nonrenewable provisional licenses to growers who demonstrate that CEQA compliance is under way . Once growers have obtained a license for cultivation, they must, among other requirements, tag all plants with radio-frequency identification tags to track the product from its point of origin to commercial sale, maintain 24-hour video surveillance of all plants, record the names of and timestamp all individuals who enter the fenced cultivation area and report the weight of any discarded plant material . Prior to sale, growers are required to hire third-party testing laboratories to confirm that their crop meets quality assurance guidelines for cannabinoid levels, moisture content, residual solvents and processing chemicals, pesticides, microbial impurities, foreign material, terpenoids, mycotoxins and heavy metals . Growers must also pay state and county cultivation taxes. As of 2019, state cultivation taxes per dry weight ounce were $9.25 for flower, $2.75 for stem and $1.29 for fresh plant . County cultivation taxes vary, and some counties have yet to develop cultivation license guidelines. Additionally, growers must pay licensed distributors to transport their cannabis from the farm to testing sites and dispensaries . Counties and municipalities may enhance state cultivation requirements or ban cannabis production entirely within their jurisdiction . The SWRCB or CDFW may also effectively ban cultivation by refusing to issue licenses in locations where they determine cultivation may have an adverse environmental impact . Further, counties and municipalities may prohibit cannabis sales or impose business or sales taxes in addition to the state’s retail sales tax rate of 15% . The cultivation licensing system was broadly intended to facilitate cannabis growers’ entrance into the legal market while protecting public safety,greenhouse racking limiting environmental impacts and preventing the distribution of illegally grown cannabis. However, the extensive cultivation and reporting criteria, coupled with the high costs of obtaining licenses, may be creating disincentives for growers to comply with the regulations. Noncompliance increases the risk of failure in the state’s policy to transition growers to legal markets. As of April 2018, the state had approved 3,490 temporary licenses for cultivation. The president of the California Growers’ Association estimated the number of the state’s cannabis growers to be around 50,000 . Compared to other forms of legal crop cultivation, little is known about cannabis production dynamics in California. The dearth of research is attributed to challenges in obtaining federal funding to study federally illicit activities and the disincentives for clandestine growers to share information with outside parties . Accounts that do exist characterize the industry as emerging in the 1960s with the back-to-the-land movement giving rise to a proliferation of small farms in California’s North Coast region . To avoid detection, cultivation took place in remote regions, including forested hillsides in Humboldt, Mendocino and Trinity counties known as the Emerald Triangle . In 1983, California collaborated with the federal Campaign Against Marijuana Program , deploying helicopters to eradicate plants on private property . Enforcement efforts increased the crop’s value in illicit markets, thereby incentivizing continued cultivation . In 1996, the Compassionate Use Act decriminalized the use and cultivation of cannabis for medical purposes in California; it allowed counties to authorize production of up to 99 plants per medical card . Accounts of medical cannabis cultivation describe small family farms, in contrast to the consolidated, intensively farmed industrial agricultural operations throughout California . In 2012 and 2013, Google Earth satellite images of Humboldt County landscapes suggested an average of 67 plants on outdoor grow sites and 86 smaller plants in greenhouses .
A comparison of Google Earth images between 2012 and 2016 in Humboldt and Mendocino counties, however, documented an 80% increase in the number of cultivation sites and a 56% increase in the average number of total plants per site . Although still small in scale compared to traditional agriculture, cannabis production was expanding, and it was expanding in part in ecologically sensitive remote watersheds, where histories of cultivation corresponded to concerns about ecological stress from water diversion and fragmented forested landscapes . The increase in cultivation sites and production densities may be due to relaxed enforcement and subsequent increased market competition. In 2012, California abandoned CAMP and replaced it with a new program, the Cannabis Eradication and Reclamation Team , which effectively reduced enforcement and redirected it to public lands . In 2017, the Drug Enforcement Administration estimated that 70% of the nation’s cannabis supply came from California . How legal cannabis production will develop remains unclear, but it will be strongly influenced by if and how existing growers participate in the state’s cannabis regulatory system. Access to legal markets might also create opportunities for growers to brand their products as socially or ecologically sustainable, or to emulate other forms of legal agriculture and organize collectively to overcome market competition . Conversely, if regulations limit access to the legal market, growers may either cease production or cultivate for illicit markets. To characterize the ecological and socioeconomic effects of cannabis policy changes and better understand cultivation practices, we conducted an anonymous survey of California cannabis growers from July 1 to Aug. 15, 2018. The objective was to document relationships between aspects of production and growers’ experiences with the legalization system and the regulatory environment. Results on cultivation practices are covered in Wilson et al. 2019 . Here, we report respondents’ experiences with legalization. Given the legal risks cannabis growers might assume when reporting their practices, we deployed an online, anonymous survey to try to access a wide range of growers. We distributed the survey through the listservs of several prominent California cannabis grower organizations in July 2018. We administered the survey using the Qualtrics survey platform , which encrypted participants’ IP addresses so that responses were collected anonymously. We estimated that 17,500 email addresses received the survey, not all of which necessarily represented cannabis growers or were active emails. Because we were unable to view the listservs or contact growers directly, and given the uncertainties surrounding estimates of the state’s number of cannabis growers, we were unable to estimate a response rate. We were also unable to follow up with growers directly to increase participation. For a full discussion of the survey methods, see Wilson et al. 2019. In the survey, we asked questions relating to compliance, including “Have you applied for a state or county license to grow cannabis?” We also asked growers to report their income received from cannabis cultivation. We determined growers who had not applied for a license but who reported income received from cannabis to be out of compliance with state and county regulations. Additionally, we asked growers three open-ended questions: respondents who indicated they had not applied for a license had an opportunity to explain why; growers were invited to comment on the state licensing system and how it could be improved; and they could share any additional information about their farms. We manually coded qualitative responses for thematic trends. We characterized farm size based on California state licensing criteria : small farms were 10,000 square feet or less, medium farms were 10,001 to 22,000 square feet and large farms were those over 22,000 square feet.