key: cord-0016438-2kft1r3l
authors: Matthay, Ellicott C.; Kiang, Mathew V.; Elser, Holly; Schmidt, Laura; Humphreys, Keith
title: Evaluation of State Cannabis Laws and Rates of Self-harm and Assault
date: 2021-03-18
journal: JAMA Netw Open
DOI: 10.1001/jamanetworkopen.2021.1955
sha: 6b1919c832f18b656aa3aa24bf81a0f1b02a4b59
doc_id: 16438
cord_uid: 2kft1r3l

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.

To confirm that our study had sufficient statistical power, we conducted a power analysis. Using the observed baseline rates of self-harm and assault with a negative binomial distribution, the main exposure measure, and a twosided test with alpha 0.05, the analysis had 80% power to detect a minimum 5.1% increase in assault and 5.3% increase in self-harm for the rarest commercialization category. eTable 2: International Classification of Diseases Clinical Modification (ICD-CM) 9th and 10th revision external cause of injury codes used to identify and classify self-harm and assault injuries Self-harm injury Assault injury ICD-9-CM  codes  T40692, T40692A, T407X2, T407X2A,  T408X2, T408X2A, T40902, T40902A,  T40992, T40992A, T410X2, T410X2A,  T411X2, T411X2A, T41202, T41202A,  T41292, T41292A, T413X2, T413X2A,  T4142XA, T415X2, T415X2A, T420X2,  T420X2A, T421X2, T421X2A, T422X2,  T422X2A, T423X2, T423X2A, T424X2,  T424X2A, T425X2, T425X2A, T426X2,  T426X2A, T4272XA, T428X2, T428X2A,  T43012, T43012A, T43022, T43022A,  T431X2, T431X2A, T43202, T43202A,  T43212, T43212A, T43222, T43222A,  T43292, T43292A, T433X2, T433X2A,  T434X2, T434X2A, T43502, T43502A,  T43592, T43592A, T43602, T43602A,  T43612, T43612A, T43622, T43622A,  T43632, T43632A, T43692, T43692A,  T438X2, T438X2A, T4392XA, T440X2,  T440X2A, T441X2, T441X2A, T442X2,  T442X2A, T443X2, T443X2A, T444X2,  T444X2A, T445X2, T445X2A, T446X2,  T446X2A, T447X2, T447X2A, T448X2,  T448X2A, T44902, T44902A, T44992,  T44992A, T450X2, T450X2A, T451X2,  T451X2A, T452X2, T452X2A, T453X2,  T453X2A, T454X2, T454X2A, T45512,  T45512A, T45522, T45522A, T45602,  T45602A, T45612, T45612A, T45622,  T45622A, T45692, T45692A, T457X2,  T457X2A, T458X2, T458X2A, T4592XA,  T460X2, T460X2A, T461X2, T461X2A,  T462X2, T462X2A, T463X2, T463X2A,  T464X2, T464X2A, T465X2, T465X2A,  T466X2, T466X2A, T467X2, T467X2A,  T468X2, T468X2A, T46902, T46902A,  T46992, T46992A, T470X2, T470X2A,  T471X2, T471X2A, T472X2, T472X2A,  T473X2, T473X2A, T474X2, T474X2A,  T475X2, T475X2A, T476X2, T476X2A,  T477X2, T477X2A, T478X2, T478X2A,  T4792XA, T480X2, T480X2A, T481X2,  T481X2A, T48202, T48202A, T48292,  T48292A, T483X2, T483X2A, T484X2,  T484X2A, T485X2, T485X2A, T486X2,  T486X2A, T48902, T48902A, T48992,  T48992A, T490X2, T490X2A, T491X2,  T491X2A, T492X2, T492X2A, T493X2,  T493X2A, T494X2, T494X2A, T495X2,  T495X2A, T496X2, T496X2A, T497X2,  T497X2A, T498X2, T498X2A, T4992XA,  T500X2, T500X2A, T501X2, T501X2A,  T502X2, T502X2A, T503X2, T503X2A,  T504X2, T504X2A, T505X2, T505X2A,  T506X2, T506X2A, T507X2, T507X2A,  T508X2, T508X2A, T50902, T50902A,   Y35092, Y35092A, Y35093, Y35093A, Y351,  Y3510, Y35101, Y35101A, Y35102,  Y35102A, Y35103, Y35103A, Y3511,  Y35111, Y35111A, Y35112, Y35112A,  Y35113, Y35113A, Y3512, Y35121,  Y35121A, Y35122, Y35122A, Y35123,  Y35123A, Y3519, Y35191, Y35191A,  Y35192, Y35192A, Y35193, Y35193A, Y352,  Y3520, Y35201, Y35201A, Y35202,  Y35202A, Y35203, Y35203A, Y3521,  Y35211, Y35211A, Y35212, Y35212A Y35492A, Y35493, Y35493A, Y358, Y3581,  Y35811, Y35811A, Y35812, Y35812A,  Y35813, Y35813A, Y3589, Y35891,  Y35891A, Y35892, Y35892A, Y35893,  Y35893A, Y359, Y3591, Y3591XA, Y3592,  Y3592XA, Y3593, Y3593XA, T360X3,  T360X3A, T361X3, T361X3A, T362X3,  T362X3A, T363X3, T363X3A, T364X3,  T364X3A, T365X3, T365X3A, T366X3,  T366X3A, T367X3, T367X3A, T368X3,  T368X3A, T3693XA, T370X3, T370X3A,  T371X3, T371X3A, T372X3, T372X3A,  T373X3, T373X3A, T374X3, T374X3A,  T375X3, T375X3A, T378X3, T378X3A,  T3793XA, T380X3, T380X3A, T381X3,  T381X3A, T382X3, T382X3A, T383X3,  T383X3A, T384X3, T384X3A, T385X3,  T385X3A, T386X3, T386X3A, T387X3,  T387X3A, T38803, T38803A, T38813,  T38813A, T38893, T38893A, T38903,  T38903A, T38993, T38993A, T39013,  T39013A, T39093, T39093A, T391X3,  T391X3A, T392X3, T392X3A, T39313,  T39313A, T39393, T39393A, T394X3,  T394X3A, T398X3, T398X3A, T3993XA,  T400X3, T400X3A, T401X3, T401X3A,  T402X3, T402X3A, T403X3, T403X3A,  T404X3, T404X3A, T405X3, T405X3A,  T40603, T40603A, T40693, T40693A,  T407X3, T407X3A, T408X3, T408X3A,  T40903, T40903A, T40993, T40993A,  T410X3, T410X3A, T411X3, T411X3A,  T41203, T41203A, T41293, T41293A,  T50992, T50992A, T50A12, T50A12A,  T50A22, T50A22A, T50A92, T50A92A,  T50B12, T50B12A, T50B92, T50B92A,  T50Z12, T50Z12A, T50Z92, T50Z92A,  T510X2, T510X2A, T511X2, T511X2A,  T512X2, T512X2A, T513X2, T513X2A,  T518X2, T518X2A, T5192XA, T520X2,  T520X2A, T521X2, T521X2A, T522X2,  T522X2A, T523X2, T523X2A, T524X2,  T524X2A, T528X2, T528X2A, T5292XA,  T530X2, T530X2A, T531X2, T531X2A,  T532X2, T532X2A, T533X2, T533X2A,  T534X2, T534X2A, T535X2, T535X2A,  T536X2, T536X2A, T537X2, T537X2A,  T5392XA, T540X2, T540X2A, T541X2,  T541X2A, T542X2, T542X2A, T543X2,  T543X2A, T5492XA, T550X2, T550X2A,  T551X2, T551X2A, T560X2, T560X2A,  T561X2, T561X2A, T562X2, T562X2A,  T563X2, T563X2A, T564X2, T564X2A,  T565X2, T565X2A, T566X2, T566X2A,  T567X2, T567X2A, T56812, T56812A,  T56892, T56892A, T5692XA, T570X2,  T570X2A, T571X2, T571X2A, T572X2,  T572X2A, T573X2, T573X2A, T578X2,  T578X2A, T5792XA, T5802XA, T5812XA,  T582X2, T582X2A, T588X2, T588X2A,  T5892XA, T590X2, T590X2A, T591X2,  T591X2A, T592X2, T592X2A, T593X2,  T593X2A, T594X2, T594X2A, T595X2,  T595X2A, T596X2, T596X2A, T597X2,  T597X2A, T59812, T59812A, T59892,  T59892A, T5992XA, T600X2, T600X2A,  T601X2, T601X2A, T602X2, T602X2A,  T603X2, T603X2A, T604X2, T604X2A,  T608X2, T608X2A, T6092XA, T6102XA,  T6112XA, T61772, T61772A, T61782,  T61782A, T618X2, T618X2A, T6192XA,  T620X2, T620X2A, T621X2, T621X2A,  T622X2, T622X2A, T628X2, T628X2A,  T6292XA, T63002, T63002A, T63012,  T63012A, T63022, T63022A, T63032,  T63032A, T63042, T63042A, T63062,  T63062A, T63072, T63072A, T63082,  T63082A, T63092, T63092A, T63112,  T63112A, T63122, T63122A, T63192,  T63192A, T632X2, T632X2A, T63302,  T63302A, T63312, T63312A, T63322,  T63322A, T63332, T63332A, T63392,  T63392A, T63412, T63412A, T63422,  T63422A, T63432, T63432A, T63442,  T63442A, T63452, T63452A, T63462,  T63462A, T63482, T63482A, T63512,  T63512A, T63592, T63592A, T63612,  T63612A, T63622, T63622A, T63632,  T63632A, T63692, T63692A, T63812,   T413X3, T413X3A, T4143XA, T415X3,  T415X3A, T420X3, T420X3A, T421X3,  T421X3A, T422X3, T422X3A, T423X3,  T423X3A, T424X3, T424X3A, T425X3,  T425X3A, T426X3, T426X3A, T4273XA,  T428X3, T428X3A, T43013, T43013A,  T43023, T43023A, T431X3, T431X3A,  T43203, T43203A, T43213, T43213A,  T43223, T43223A, T43293, T43293A,  T433X3, T433X3A, T434X3, T434X3A,  T43503, T43503A, T43593, T43593A,  T43603, T43603A, T43613, T43613A,  T43623, T43623A, T43633, T43633A,  T43693, T43693A, T438X3, T438X3A,  T4393XA, T440X3, T440X3A, T441X3,  T441X3A, T442X3, T442X3A, T443X3,  T443X3A, T444X3, T444X3A, T445X3,  T445X3A, T446X3, T446X3A, T447X3,  T447X3A, T448X3, T448X3A, T44903,  T44903A, T44993, T44993A, T450X3,  T450X3A, T451X3, T451X3A, T452X3,  T452X3A, T453X3, T453X3A, T454X3,  T454X3A, T45513, T45513A, T45523,  T45523A, T45603, T45603A, T45613,  T45613A, T45623, T45623A, T45693,  T45693A, T457X3, T457X3A, T458X3,  T458X3A, T4593XA, T460X3, T460X3A,  T461X3, T461X3A, T462X3, T462X3A,  T463X3, T463X3A, T464X3, T464X3A,  T465X3, T465X3A, T466X3, T466X3A,  T467X3, T467X3A, T468X3, T468X3A,  T46903, T46903A, T46993, T46993A,  T470X3, T470X3A, T471X3, T471X3A,  T472X3, T472X3A, T473X3, T473X3A,  T474X3, T474X3A, T475X3, T475X3A,  T476X3, T476X3A, T477X3, T477X3A,  T478X3, T478X3A, T4793XA, T480X3,  T480X3A, T481X3, T481X3A, T48203,  T48203A, T48293, T48293A, T483X3,  T483X3A, T484X3, T484X3A, T485X3,  T485X3A, T486X3, T486X3A, T48903,  T48903A, T48993, T48993A, T490X3,  T490X3A, T491X3, T491X3A, T492X3,  T492X3A, T493X3, T493X3A, T494X3,  T494X3A, T495X3, T495X3A, T496X3,  T496X3A, T497X3, T497X3A, T498X3,  T498X3A, T4993XA, T500X3, T500X3A,  T501X3, T501X3A, T502X3, T502X3A,  T503X3, T503X3A, T504X3, T504X3A,  T505X3, T505X3A, T506X3, T506X3A,  T507X3, T507X3A, T508X3, T508X3A,  T50903, T50903A, T50993, T50993A,  T50A13, T50A13A, T50A23, T50A23A,  T50A93, T50A93A, T50B13, T50B13A,  T50B93, T50B93A, T50Z13, T50Z13A,  T50Z93, T50Z93A, T510X3, T510X3A,  T63812A, T63822, T63822A, T63832,  T63832A, T63892, T63892A, T6392XA,  T63712, T63712A, T63792, T63792A,  T6402XA, T6482XA, T650X2, T650X2A,  T651X2, T651X2A, T65212, T65212A,  T65222, T65222A, T65292, T65292A,  T653X2, T653X2A, T654X2, T654X2A,  T655X2, T655X2A, T656X2, T656X2A,  T65812, T65812A, T65822, T65822A,  T65832, T65832A, T65892, T65892A,  T6592XA, T71112, T71112A, T71122,  T71122A, T71132, T71132A, T71152,  T71152A, T71162, T71162A, T71192,  T71192A, T71222, T71222A, T71232,  T71232A   T511X3, T511X3A, T512X3, T512X3A,  T513X3, T513X3A, T518X3, T518X3A,  T5193XA, T520X3, T520X3A, T521X3,  T521X3A, T522X3, T522X3A, T523X3,  T523X3A, T524X3, T524X3A, T528X3,  T528X3A, T5293XA, T530X3, T530X3A,  T531X3, T531X3A, T532X3, T532X3A,  T533X3, T533X3A, T534X3, T534X3A,  T535X3, T535X3A, T536X3, T536X3A,  T537X3, T537X3A, T5393XA, T540X3,  T540X3A, T541X3, T541X3A, T542X3,  T542X3A, T543X3, T543X3A, T5493XA,  T550X3, T550X3A, T551X3, T551X3A,  T560X3, T560X3A, T561X3, T561X3A,  T562X3, T562X3A, T563X3, T563X3A,  T564X3, T564X3A, T565X3, T565X3A,  T566X3, T566X3A, T567X3, T567X3A,  T56813, T56813A, T56893, T56893A,  T5693XA, T570X3, T570X3A, T571X3,  T571X3A, T572X3, T572X3A, T573X3,  T573X3A, T578X3, T578X3A, T5793XA,  T5803XA, T5813XA, T582X3, T582X3A,  T588X3, T588X3A, T5893XA, T590X3,  T590X3A, T591X3, T591X3A, T592X3,  T592X3A, T593X3, T593X3A, T594X3,  T594X3A, T595X3, T595X3A, T596X3,  T596X3A, T597X3, T597X3A, T59813,  T59813A, T59893, T59893A, T5993XA,  T600X3, T600X3A, T601X3, T601X3A,  T602X3, T602X3A, T603X3, T603X3A,  T604X3, T604X3A, T608X3, T608X3A,  T6093XA, T6103XA, T6113XA, T61773,  T61773A, T61783, T61783A, T618X3,  T618X3A, T6193XA, T620X3, T620X3A,  T621X3, T621X3A, T622X3, T622X3A,  T628X3, T628X3A, T6293XA, T63003,  T63003A, T63013, T63013A, T63023,  T63023A, T63033, T63033A, T63043,  T63043A, T63063, T63063A, T63073,  T63073A, T63083, T63083A, T63093,  T63093A, T63113, T63113A, T63123,  T63123A, T63193, T63193A, T632X3,  T632X3A, T63303, T63303A, T63313,  T63313A, T63323, T63323A, T63333,  T63333A, T63393, T63393A, T63413,  T63413A, T63423, T63423A, T63433,  T63433A, T63443, T63443A, T63453,  T63453A, T63463, T63463A, T63483,  T63483A, T63513, T63513A, T63593,  T63593A, T63613, T63613A, T63623,  T63623A, T63633, T63633A, T63693,  T63693A, T63813, T63813A, T63823,  T63823A, T63833, T63833A, T63893,  T63893A, T6393XA, T63713, T63713A,  T63793, T63793A, T6403XA, T6483XA,  T650X3, T650X3A, T651X3, T651X3A,  T65213, T65213A, T65223, T65223A,  T65293, T65293A, T653X3, T653X3A,  T654X3, T654X3A, T655X3, T655X3A,  T656X3, T656X3A, T65813, T65813A,  T65823, T65823A, T65833, T65833A,  T65893, T65893A, T6593XA, T71113,  T71113A, T71123, T71123A, T71133,  T71133A, T71143, T71143A, T71153,  T71153A, T71163, T71163A, T71193,  T71193A, T71223, T71223A, T71233 .4 (37.9 -42.9) Abbreviations: CI: confidence interval eFigure 1: Adjusted associations of medical and recreational cannabis commercialization with self-harm and assault injury rates, using unique claims as the denominator for outcome rates, for the overall study population, [2003] [2004] [2005] [2006] [2007] [2008] [2009] [2010] [2011] [2012] [2013] [2014] [2015] [2016] [2017] Legend: Points represent the estimated rate ratio for the association of each type of cannabis commercialization with self-harm or assault injuries, relative to state-months not adopting any medical or recreational cannabis legalization over the same period. Bars represent the corresponding 95% confidence intervals. The primary analysis used the number of insured beneficiaries in the given state and month as the denominator when calculating rates of self-harm and assault. In this sensitivity analysis, we used unique claims (the number of unique claims made per state-month) as the denominator, to account for changes in overall utilization over time. Legend: Points represent the estimated rate ratio for the association of each type of cannabis commercialization with self-harm or assault injuries, relative to state-months not adopting any medical or recreational cannabis legalization over the same period. Bars represent the corresponding 95% confidence intervals. The primary analysis used the number of insured beneficiaries in the given state and month as the denominator when calculating rates of self-harm and assault. In this sensitivity analysis, we used active members (the number of unique members who filed at least one claim per state month), because this approach is more robust to high-utilizing members. Legend: Points represent the estimated rate ratio for the association of each type of cannabis commercialization with self-harm or assault injuries, relative to state-months not adopting any medical or recreational cannabis legalization over the same period. Bars represent the corresponding 95% confidence intervals. Legend: Points represent the estimated rate ratio for the association of each type of cannabis commercialization with self-harm or assault injuries, relative to state-months not adopting any medical or recreational cannabis legalization over the same period. Bars represent the corresponding 95% confidence intervals. Legend: Points represent the estimated rate ratio for the association of each type of cannabis commercialization with self-harm or assault injuries, relative to state-months not adopting any medical or recreational cannabis legalization over the same period. Bars represent the corresponding 95% confidence intervals. Legend: Points represent the estimated rate ratio for the association of naloxone overdose prevention laws (a negative control exposure) with self-harm or assault injuries, relative to state-months not adopting such laws over the same period. The bars represent the corresponding 95% confidence intervals. 8: Adjusted associations of hypothetical, randomly generated law changes as a negative control exposure with self-harm and assault injury rates, for the overall study population, [2003] [2004] [2005] [2006] [2007] [2008] [2009] [2010] [2011] [2012] [2013] [2014] [2015] [2016] [2017] Legend: Points represent the estimated rate ratio for the association of a hypothetical, randomly generated policy change (a negative control exposure) with self-harm or assault injuries, relative to state-months not adopting such "laws" over the same period. The bars represent the corresponding 95% confidence intervals. 

Self−harm Assault eFigure 9: Adjusted associations of medical and recreational cannabis commercialization with self-harm and assault injury rates, with additional adjustment for linear state-specific time trends, for the overall study population, [2003] [2004] [2005] [2006] [2007] [2008] [2009] [2010] [2011] [2012] [2013] [2014] [2015] [2016] [2017] Legend: Points represent the estimated rate ratio for the association of each type of cannabis commercialization with self-harm or assault injuries, relative to state-months not adopting any medical or recreational cannabis legalization over the same period. Bars represent the corresponding 95% confidence intervals. Legend: Points represent the estimated rate ratio for the association of each type of cannabis commercialization with self-harm or assault injuries, relative to state-months with medical cannabis without dispensaries. Bars represent the corresponding 95% confidence intervals. The primary analysis used all state-months 2003-2017, including statemonths with and without cannabis legalization laws. This analysis used only state-months in which some form of cannabis legalization was effective, with the most stringent category (medical, without dispensaries) as the reference category. Commercialization refers to the presence of dispensaries in either medical or recreational cannabis states. "Recreational with dispensaries" refers to the estimate for an interaction term between recreation (versus medical) legalization and commercialization. This analytic specification was not tested for analyses by age group and gender because such analyses effectively involve third-order interactions and were under powered. Legend: Points represent the estimated rate ratio for the association of each type of cannabis commercialization with assault injuries, relative to state-months not adopting any medical or recreational cannabis legalization over the same period. Bars represent the corresponding 95% confidence intervals. The primary analysis used the number of insured beneficiaries in the given state and month as the denominator when calculating rates of self-harm and assault. In this sensitivity analysis, we used unique claims (the number of unique claims made per state-month) as the denominator, to account for changes in overall utilization over time. 

eFigure 13: Adjusted associations of medical and recreational cannabis commercialization with self-harm injury rates, using unique claims as the denominator for outcome rates, by age group and gender, [2003] [2004] [2005] [2006] [2007] [2008] [2009] [2010] [2011] [2012] [2013] [2014] [2015] [2016] [2017] Legend: Points represent the estimated rate ratio for the association of each type of cannabis commercialization with self-harm injuries, relative to state-months not adopting any medical or recreational cannabis legalization over the same period. Bars represent the corresponding 95% confidence intervals. The primary analysis used the number of insured beneficiaries in the given state and month as the denominator when calculating rates of self-harm and assault. In this sensitivity analysis, we used unique claims (the number of unique claims made per state-month) as the denominator, to account for changes in overall utilization over time. 

Rate Ratio eFigure 14: Adjusted associations of medical and recreational cannabis commercialization with assault injury rates, using active members as the denominator for outcome rates, by age group and gender, [2003] [2004] [2005] [2006] [2007] [2008] [2009] [2010] [2011] [2012] [2013] [2014] [2015] [2016] [2017] Legend: Points represent the estimated rate ratio for the association of each type of cannabis commercialization with assault injuries, relative to state-months not adopting any medical or recreational cannabis legalization over the same period. Bars represent the corresponding 95% confidence intervals. The primary analysis used the number of insured beneficiaries in the given state and month as the denominator when calculating rates of self-harm and assault. In this sensitivity analysis, we used active members (the number of unique members who filed at least one claim per state month), because this approach is more robust to high-utilizing members. 

eFigure 15: Adjusted associations of medical and recreational cannabis commercialization with self-harm injury rates, using active members as the denominator for outcome rates, by age group and gender, [2003] [2004] [2005] [2006] [2007] [2008] [2009] [2010] [2011] [2012] [2013] [2014] [2015] [2016] [2017] Legend: Points represent the estimated rate ratio for the association of each type of cannabis commercialization with self-harm injuries, relative to state-months not adopting any medical or recreational cannabis legalization over the same period. Bars represent the corresponding 95% confidence intervals. The primary analysis used the number of insured beneficiaries in the given state and month as the denominator when calculating rates of self-harm and assault. In this sensitivity analysis, we used active members (the number of unique members who filed at least one claim per state month), because this approach is more robust to high-utilizing members. 

Rate Ratio eFigure 16: Adjusted associations of medical and recreational cannabis commercialization with assault injury rates, adjusted for firearm availability, without the District of Columbia, by age group and gender, 2003-2017 Legend: Points represent the estimated rate ratio for the association of each type of cannabis commercialization with assault injuries, relative to state-months not adopting any medical or recreational cannabis legalization over the same period. Bars represent the corresponding 95% confidence intervals. Legend: Points represent the estimated rate ratio for the association of each type of cannabis commercialization with self-harm injuries, relative to state-months not adopting any medical or recreational cannabis legalization over the same period. Bars represent the corresponding 95% confidence intervals. Legend: Points represent the estimated rate ratio for the association of each type of cannabis commercialization with assault injuries, relative to state-months not adopting any medical or recreational cannabis legalization over the same period. Bars represent the corresponding 95% confidence intervals. Legend: Points represent the estimated rate ratio for the association of each type of cannabis commercialization with assault injuries, relative to state-months not adopting any medical or recreational cannabis legalization over the same period. Bars represent the corresponding 95% confidence intervals. Legend: Points represent the estimated rate ratio for the association of each type of cannabis commercialization with self-harm injuries, relative to state-months not adopting any medical or recreational cannabis legalization over the same period. Bars represent the corresponding 95% confidence intervals. Legend: Points represent the estimated rate ratio for the association of naloxone overdose prevention laws (a negative control exposure) with assault injuries, relative to state-months not adopting such laws over the same period. The bars represent the corresponding 95% confidence intervals. Legend: Points represent the estimated rate ratio for the association of naloxone overdose prevention laws (a negative control exposure) with self-harm injuries, relative to state-months not adopting such laws over the same period. The bars represent the corresponding 95% confidence intervals. 

Rate Ratio eFigure 24: Adjusted associations of hypothetical, randomly generated law changes as a negative control exposure with assault injury rates, by age group and gender, [2003] [2004] [2005] [2006] [2007] [2008] [2009] [2010] [2011] [2012] [2013] [2014] [2015] [2016] [2017] Legend: Points represent the estimated rate ratio for the association of a hypothetical, randomly generated policy change (a negative control exposure) with assault injuries, relative to state-months not adopting such "laws" over the same period. The bars represent the corresponding 95% confidence intervals. 

Rate Ratio eFigure 25: Adjusted associations of hypothetical, randomly generated law changes as a negative control exposure with self-harm injury rates, by age group and gender, [2003] [2004] [2005] [2006] [2007] [2008] [2009] [2010] [2011] [2012] [2013] [2014] [2015] [2016] [2017] Legend: Points represent the estimated rate ratio for the association of a hypothetical, randomly generated policy change (a negative control exposure) with self-harm injuries, relative to state-months not adopting such "laws" over the same period. The bars represent the corresponding 95% confidence intervals. 

Rate Ratio

Adjusted associations of medical and recreational cannabis commercialization with self-harm injury rates, with recreational dispensary categories disaggregated by THC dosage-related restrictions, by age group and gender

Legend: Points represent the estimated rate ratio for the association of each type of cannabis commercialization with self-harm injuries, relative to state-months not adopting any medical or recreational cannabis legalization over the same period

Adjusted associations of medical and recreational cannabis commercialization with assault injury rates, with additional adjustment for linear state-specific time trends, by age group and gender

Legend: Points represent the estimated rate ratio for the association of each type of cannabis commercialization with assault injuries, relative to state-months not adopting any medical or recreational cannabis legalization over the same period

Adjusted associations of medical and recreational cannabis commercialization with self-harm injury rates, with additional adjustment for linear state-specific time trends, by age group and gender

Legend: Points represent the estimated rate ratio for the association of each type of cannabis commercialization with self-harm injuries, relative to state-months not adopting any medical or recreational cannabis legalization over the same period. Bars represent the corresponding 95% confidence intervals. Self-harm claims for women aged 65 and older were very rare

Adjusted associations of medical and recreational cannabis commercialization with assault injury rates, for states with cannabis legalization, by age group and gender

Legend: Points represent the estimated rate ratio for the association of each type of cannabis commercialization with assault injuries, relative to state-months with medical cannabis without dispensaries. The primary analysis used all state-months 2003-2017, including state-months with and without cannabis legalization laws. This analysis used only state-months in which some form of cannabis legalization was effective, with the most stringent category (medical, without dispensaries) as the reference category. Bars represent the corresponding 95% confidence intervals. Assault claims for women aged 65 and older were rare in cannabis legalization states

Adjusted associations of medical and recreational cannabis commercialization with self-harm injury rates, for states with cannabis legalization, by age group and gender

Legend: Points represent the estimated rate ratio for the association of each type of cannabis commercialization with self-harm injuries, relative to state-months with medical cannabis without dispensaries. The primary analysis used all state-months 2003-2017, including state-months with and without cannabis legalization laws. This analysis used only state-months in which some form of cannabis legalization was effective, with the most stringent category (medical, without dispensaries) as the reference category. Bars represent the corresponding 95% confidence intervals. Self-harm claims for women aged 65