Our use of provider-assigned diagnoses restricted our sample to ICD-9 codes assigned during health plan visits. This method is vulnerable to diagnostic under-estimation; and thus, the rates of bipolar and schizophrenia may be somewhat higher than we report. Another potential limitation with the methods used to select the sample is that we required a single mention of an ICD-9 code for SMI during the study period to link the patient with that diagnosis and included all current and existing diagnoses . While this single mention methodology is well established, it could result in overestimation if diagnoses only mentioned one time in the EHR are more likely to be inaccurate. Since patients with bipolar or schizophrenia could have multiple behavioral diagnoses. Thus, our results should be interpreted with caution until confirmatory studies are conducted in mutually exclusive SMI groups. All data are cross-sectional; and thus, no directionality can be assumed in associations between conditions, and associations do not imply cause-and-effect relationships. Long-term follow-up studies will be required to capture the full impact medical comorbidities have on the course and outcome of individuals with SMI. The reasons why having SMI is associated with disproportionately high odds of having medical comorbidities are complex and multi-factorial and future studies will need to continue to monitor medical comorbidity in this population as health policies evolve. We found having a SMI was associated with higher odds of having several medical comorbidities as well as chronic and severe medical conditions,rolling grow table even in an integrated health care system where patients have insurance coverage and broad access to care.
Our results suggest that that SMI patients have high medical needs, and implementing enhanced outreach efforts focused on prevention, early diagnosis, and treatment of medical comorbidities may help reduce associated morbidity and mortality and improve overall prognosis in this population.In November 1996, California became the first state to legalize the use of medical marijuana. Since then, a total of 23 states have passed medical marijuana laws , along with 4 states and Washington D.C. legalizing the recreational use of marijuana. With marijuana legislation continuously being seen on state ballots, it is important to research and understand the effects it brings to society. To conduct our research, we will be looking specifically at the effect of medical marijuana use in California. The goal of this paper is to observe the effects that medical marijuana has on crime rates and other drug and alcohol use. A specific question to be answered is whether or not marijuana can be a substitute, rather than a complement, for other illegal drugs and alcohol, resulting in a decrease in crime and drug and alcohol-induced deaths. To discover an answer, we will look at medical marijuana, crime, arrest, unemployment, and mortality rates in California counties from 2005-2014. The arrest and mortality rates will be used specifically to examine the possibility of marijuana being a substitute drug. Today, there are approximately 572,762 medical marijuana patients in California, which is equivalent to 1.49% of California’s population.While recreational use of marijuana has not been legalized in California, it is estimated that 9% of Californians use marijuana.If recreational marijuana use is legalized in California, it is possible that the percentage of marijuana users will increase. Given that California already has numerous marijuana farms and is predicted to provide 60-70% of the United States’ crop if legalized within the state, according to the International Business Times, it is pertinent to analyze the outcomes marijuana has on California’s society today. In 2010, the number one cause of death among 25-64 year olds in California was drug overdose.Many individuals have grown up with the notion that marijuana is a gateway drug to other illicit “hard” drugs. These other substances could include cocaine, heroin, methamphetamines, and prescription drugs, all of which can be extremely addicting and fatal. Since 1999, deaths from painkiller drug overdoses have increased 400% for women and 237% for men.This causes us to think of potential solutions for fatal substance abuse. If medical marijuana can be offered as a substitute drug, will it decrease drug-poisoning deaths? According to a survey implemented by the U.S. Department of Health and Human Services from 2005 to 2011, illegal drug use percentages were much higher in unemployed individuals than individuals with some sort of employment.Specifically, it was shown that 18% of the unemployed were involved in illegal drug use, compared to 10% of part-time workers and 8% of full-time workers. This causes us to question whether or not there’s a relationship between drug use and unemployment. When California passed Proposition 215, referred to as the California Compassion Use Act, it allowed patients, along with their primary physicians, to possess and grow marijuana for medical use, once given a referral from a California-licensed doctor. In 2004, California passed SB 420 to supplement Prop 215. The SB 420 specified the amount of marijuana each patient could possess and cultivate and created a voluntary, statewide, ID database through California health departments. This database is run by the California Department of Public Health and will be used to estimate marijuana use for this report. While both Prop 215 and SB420 protect patients and physicians from arrest in California, marijuana continues to be a federal crime, where there is no differentiation between medical and recreational marijuana use. Currently, the Drug Enforcement Administration has marijuana listed as a Schedule I drug, defined as a drug with the highest potential for danger and abuse and is listed along with heroin, LSD, and ecstasy. Schedule I drugs are assumed worse in comparison to Schedule II drugs, which are recognized to be less abusive. Schedule II drugs include cocaine, methamphetamines, and other highly addictive prescriptions. According to the Office of National Drug Control Policy, the reason marijuana legalization is refused at the national level, is because marijuana use is believed to increase the use in other illicit drugs.This brings us back to the question of whether or not marijuana can act as a substitute, rather than a “gateway”, to other hard drugs. While there has been little to no research done in the area of recreational marijuana, there have been many articles published on the effects of medical marijuana legalization. In 2013, Anderson et al. published a paper that studied the effects of MMLs on traffic fatalities across the nation by using alcohol consumption as an instrument. The authors first used price data to observe the effects on the marijuana market after the MML took effect. They found that the supply of high-grade marijuana dramatically increased, while the lower quality cannabis was moderately impacted. Getting to the basis of their main goal, they used data on traffic fatalities within a 20-year period, across 14 states, to determine if marijuana was a substitute for alcohol. It was discovered that there was an 8-11% decrease in traffic fatalities within the first year of legalization with an even larger effect on traffic fatalities involving alcohol consumption. The authors then used individual behavioral data to examine the probability of consuming alcohol in the past month, binge drinking, and the number of drinks consumed after the MML took place. They found that these probabilities drastically decreased after the legalization occurred. When looking at alcohol sales, it was also discovered that there was a decline of 5% on beer consumption in the age range of 18-29. The MMLs were then used as an instrument of beer consumption to establish the amount of traffic fatalities. It was deduced that for every 10% increase in beer sales per capita, alcohol related traffic fatalities increased by 24%. The article goes on to conclude that marijuana does have a substitution effect on alcohol, especially among young adults, which inherently declined traffic fatalities.There is currently a working paper called “The Effect of Medical Marijuana Laws on Marijuana, Alcohol, and Hard Drug Use,” where Hefei Wen studied these effects using geographic identifiers and by estimating a state-specific time trend model that included two-way fixed effects. It was discovered that the relative probability of marijuana use among individuals over 21 increased by 16%, the frequency of marijuana use increased by 12-17%, and marijuana abuse and dependency increased by 15-27%. While there was an overall increase in marijuana use after MMLs went into effect,vertical grow rack there was no strong evidence that showed marijuana use increased in youth. While the authors predicted that there could be a spillover effect of marijuana on other substances, there was no significant evidence that marijuana caused increases in alcohol and other drug use. A more recent study done through the Drug and Alcohol Review examined medical marijuana as a substitute for alcohol, prescription drugs, and other illicit substances. The data was taken from a cross-sectional survey, completed online by 473 Canadian medical marijuana patients. This included an 80.3% substitution rate for prescription drugs, a 51.7% substitution rate for alcohol, and a 32.6% substitution rate for other illicit substances. These rates serve as evidence that marijuana can “play a harm reduction role in the context of use of these substances, and may have implications for abstinence-based substance use treatment approaches.”While these results show significant effects for marijuana substitution, there are an estimated 2.3 million users of cannabis in Canada alone, making it difficult to assume a survey of only medical marijuana patients represents the entire population of all marijuana users. An additional study was done through the University of Virginia in 2014 that examined how MMLs affect crime rates.The author, Catherine Alford, decided to use difference-in-differences estimations where she controlled for state specific crime trends by collecting data across states over time from 1995-2012. It was discovered that after the implementation of MMLs, overall property crime and robbery rates increased. However, if the MMLs allowed for home cultivation, robbery rates actually decreased by about 10%. While these results show a positive relationship between MMLs and the previously mentioned crime rates, there was no statistically significant effect on violent crime rates. However, a study done in 2012, by the Center on Juvenile and Criminal Justice, showed that after California passed the SB 1449 for the decriminalization of marijuana, youth crime rates were at an all-time low.The SB 1449 allowed for a small possession of marijuana to count as an infraction, instead of a misdemeanor. Within a one-year period from 2010-2011, youth arrests declined by 16% for violent crime, 26% for homicide, and 50% for drug arrests. The author, Mike Males, concluded that the only significant explanations for a dramatic decline in juvenile crime rates would be the passing of SB 1449 and the improvement of socio-economic programs in California’s poor neighborhoods. In the previous reports examined, crime rates, drug and alcohol use, and traffic fatalities were all studied after the passing of MMLs among multiple states to discover any significant effects. While my proposed project would like to examine both crime rates and drug use affected by marijuana, it will look purely at California county data across a 10-year period and will not focus on age-specific crimes. The following report will also include an analysis of how the issuance of medical marijuana identification cards affects other drug and alcohol use, controlling for unemployment. The methodology used to answer the research questions above will be a series of multiple regressions with county and year fixed effects. To begin the analysis, we will determine how MMIC issuance affects crime rates. This regression will include unemployment as a right hand side variable to control for variations in the workforce. A regression will be run for every type of crime rate, as well as for total crime, in order to discover if marijuana has individual effects on different types of crime. In addition to regressing crime rates on MMICs, drug and alcohol arrest rates will be regressed on MMICs to examine if there’s a substitution effect between marijuana and other drugs and alcohol. Because arrest and crime rates do not depend solely on MMICs, we will also include unemployment rates as a right hand variable. After analyzing the number of MMICs on crime and arrest rates, drug, alcohol, and other mortality rates will be regressed on the number of MMICs issued per county.