Evaluation of State Cannabis Laws and Rates of Self-harm and Assault

This cohort study examines the incidence of self-harm and assault injuries in the US since the legalization of medical as well as recreational use of cannabis. Question Are state cannabis legalization laws with varying degrees of commercialization associated with rates of self-harm or assault injuries? Findings In this cohort study based on health insurance claims data from 75 395 344 beneficiaries between 2003 and 2017, rates of self-harm injuries among males younger than 40 years increased more in states legalizing recreational cannabis dispensaries compared with states without cannabis legalization laws. For other age and sex groups and for more restrictive legalization approaches, no association with self-harm and assault was found. Meaning States with recreational cannabis may benefit from monitoring levels of self-harm as a potential consequence of legalization. Importance State cannabis laws are changing rapidly. Research is inconclusive about their association with rates of self-harm and assault. Existing studies have not considered variations in cannabis commercialization across states over time. Objective To evaluate the association of state medical and recreational cannabis laws with self-harm and assault, overall and by age and sex, while considering varying degrees of commercialization. Design, Setting, and Participants Using a cohort design with panel fixed-effects analysis, within-state changes in claims for self-harm and assault injuries before and after changes in cannabis laws were quantified in all 50 US states and the District of Columbia. Comprehensive claims data on commercial and Medicare Advantage health plan beneficiaries from January 1, 2003, to December 31, 2017, grouped by state and month, were evaluated. Data analysis was conducted from January 31, 2020, to January 21, 2021. Exposures Categorical variable that indexed the degree of cannabis legalization in each state and month based on law type (medical or recreational) and operational status of dispensaries (commercialization). Main Outcomes and Measures Claims for self-harm and assault injuries based on International Classification of Diseases codes. Results The analysis included 75 395 344 beneficiaries (mean [SD] age, 47 [22] years; 50% female; and median follow-up, 17 months [interquartile range, 8-36 months]). During the study period, 29 states permitted use of medical cannabis and 11 permitted recreational cannabis. Point estimates for populationwide rates of self-harm and assault injuries were higher in states legalizing recreational cannabis compared with states with no cannabis laws, but these results were not statistically significant (adjusted rate ratio [aRR] assault, recreational dispensaries: 1.27; 95% CI, 0.79-2.03;self-harm, recreational dispensaries aRR: 1.15; 95% CI, 0.89-1.50). Results varied by age and sex with no associations found except for states with recreational policies and self-harm among males younger than 40 years (aRR <21 years, recreational without dispensaries: 1.70; 95% CI, 1.11-2.61; aRR aged 21-39 years, recreational dispensaries: 1.46; 95% CI, 1.01-2.12). Medical cannabis was generally not associated with self-harm or assault injuries populationwide or among age and sex subgroups. Conclusions and Relevance Recreational cannabis legalization appears to be associated with relative increases in rates of claims for self-harm among male health plan beneficiaries younger than 40 years. There was no association between cannabis legalization and self-harm or assault, for any other age and sex group or for medical cannabis. States that legalize but still constrain commercialization may be better positioned to protect younger male populations from unintended harms.

Automated summary

This cohort study examined the incidence of self-harm and assault injuries in the US after the legalization of medical and recreational cannabis. Results showed that recreational cannabis legalization was associated with higher self-harm rates among males under 40 years old, but not in other age and sex groups or with medical cannabis. States with recreational cannabis laws may benefit from monitoring self-harm rates as a potential consequence of legalization.