Abstract
Background and Objectives
Cannabis use is increasing in the United States, and, on average, those consuming medical cannabis report more frequent cannabis use than those who use recreationally. The present analyses focus on the prevalence and correlates of working under the influence of cannabis (WUIC) amongst individuals with chronic pain who use cannabis medically.
Methods
Adults were recruited from medical cannabis certification clinics in Michigan and individuals who were employed in the past 6 months were included in the analytic sample (N = 362). Unadjusted and adjusted logistic regressions were estimated to examine factors associated with WUIC. Descriptive analyses examined WUIC by types of employment.
Results
WUIC was reported by 34% (n = 123) of employed medical cannabis patients. After adjusting for other factors, older age and having episodes of 6+ drinks were significantly associated with lower odds of WUIC. History of driving under the influence of cannabis, reporting three+ hours high on cannabis per day, and using 0.5 oz+ of cannabis per week were all significantly associated with higher odds of WUIC.
Discussion and Conclusions
Amongst individuals who use cannabis for pain and are in the workforce, WUIC is relatively common. This may be particularly concerning in jobs that are safety‐sensitive. Prevention efforts for WUIC might focus on those who use cannabis several times per day and might consider how to balance the needs for pain management with workplace‐related roles.
Scientific Significance
The current study extends knowledge around the prevalence and characteristics of individuals using medical cannabis who engage in WUIC.
INTRODUCTION
American workplaces are facing unprecedented challenges related to the rapidly evolving environment of cannabis legalization and the increasing use of cannabis amongst employees. 1 Cannabis is one of the most commonly used psychoactive substances in the United States. 2 , 3 , 4 As of 2023, 39 states including the District of Columbia have legalized use of cannabis for qualifying medical conditions. 5 In 2022, nearly 59 million adults used cannabis in the past year; approximately 25% of adults who used cannabis in the past year had a full‐time job and 28% had a part‐time job. 6 Given access to cannabis for medical purposes across much of the United States, it is important to understand how cannabis consumption relates to employment behaviours and working under the influence of cannabis (WUIC). However, a recent systematic review concluded that data on the relationship between WUIC and work safety was limited and the results are inconclusive. 7 In one of the few existing studies of links between cannabis use and work‐related outcomes, a national study of employment data from postal workers found that those who tested positive for cannabis in a pre‐employment screening had 55% more industrial accidents, 85% more injuries, and 75% greater absenteeism compared to those who tested negative. 8 In addition, the National Safety Council (NSC) released a position statement in 2019 signifying that cannabis impacts psychomotor skills and cognitive ability and that there is no level of cannabis use that is safe or acceptable for employees who work in safety‐sensitive positions that engage in high‐risk and safety‐related job functions. 9 It is imperative to close the knowledge gap in understanding the context and temporality of impairment to assess the causal relation between cannabis use and negative consequences of WUIC.
Although data on cannabis use and workplace safety and health are limited, the implications for workplace safety are critical to understand. 7 The most concerning potential negative effects of cannabis use on workplace safety relate to sedation, disorientation, impaired judgement, lack of concentration, and slowed fine motor skills, all of which can contribute to delayed decision‐making, impaired learning, and memory and attention deficits 10 and potentially heighten the risk for injury in the workplace. The implications of these potential effects likely differ depending on their degree of impairment due to cannabis use as well as the context of work (e.g., whether one is highly impaired and/or workplace activities involve safety‐sensitive activities). There are also less risky—but still potentially harmful—consequences of acute cannabis use, such as reduced productivity and slower decision‐making, which are important to understand. 11 , 12 In addition, there are gaps in knowledge guiding workplace policies surrounding cannabis consumption, including those related to medical cannabis use. National survey data indicate that about a third of those who used cannabis medically reported daily cannabis use compared to 11% amongst those who reported recreational use, exclusively. 13 Given this context, there is an urgent need to better understand the extent to which this higher frequency of cannabis use might lead to a greater prevalence of WUIC.
Medical cannabis patients may be at particularly high risk for WUIC, given their high frequency of use and risk behaviours following the use of cannabis, including driving. 13 , 14 , 15 Nonetheless, little is known about the prevalence and characteristics of individuals using medical cannabis who engage in WUIC. In addition, prior research on WUIC did not take medical cannabis use into account nor did it specifically examine the extent to which individuals who use cannabis report feeling the effects of cannabis while working. Thus, the aim of the present study was to examine the prevalence and correlates of WUIC amongst employed adults seeking medical cannabis certification or recertification for moderate/severe pain, the most commonly reported reason for medical cannabis use. 16 , 17 , 18
METHODS
Participants and procedures
Between February 2014 and June 2015, individuals aged 21+ years seeking medical cannabis certification or recertification were recruited from three medical cannabis certification clinics in Michigan as part of a longitudinal study (methods detailed previously) 19 ; note that in Michigan, about 93% of individuals seeking medical cannabis certifications did so for severe and chronic pain. 20 Potential participants were approached by trained research assistants (RAs) in clinic areas, provided consent, and self‐administered screening surveys to determine eligibility for the study (i.e., pain level of >5 out of 10 in the past month; exclusions: pregnant women, seeking certification/recertification for Alzheimer's disease or cancer). Individuals with Alzheimer's disease were excluded due to concerns about the accuracy of self‐reported responses in those with advanced cognitive decline. Additionally, individuals with cancer were excluded because the larger study focused on those with non‐cancer pain, which was, at the time in Michigan, a separate qualifying condition for medical cannabis certification. However, note that cancer and Alzheimer's disease are rare in terms of qualifying conditions, at 4.5% and 0.05%, respectively, in Michigan during the study year. 20 Of the 801 participants who were consented, enroled in the longitudinal study, and answered baseline surveys, 362 (45.2%) patients were employed at least part‐time in the past 6 months and provided data on items assessing past 6 month WUIC; these individuals comprise the present analytic sample. Compensation was $10 for screening and $30 for the baseline survey. Incentive amounts were determined using several factors to ensure that the compensation is fair, ethical, and compliant with institutional and regulatory guidelines at the time of the prior study. Procedures were approved by the University of Michigan Institutional Review Board.
Measures
We used standard assessment items created for the study to query basic demographics (e.g., age, sex, race). To measure the past 6‐month WUIC behaviour, we also used a single item created for the study, ‘In your past 6 months, have you ever been high or used marijuana on your job? (yes/no)’. We assessed substance use with past 6‐month measures of drinking 6+ alcoholic drinks on at least one occasion (yes/no) and illicit drug use or misuse of prescription sedatives, stimulants, and/or opioids (yes/no). 21 , 22 We developed two items for this study to assess cannabis use patterns (i.e., hours high per day, average quantity per week in the past month. To assess driving under the influence of cannabis (DUIC) behaviours in the past 6 months, we adapted an item from prior work in young adults. 23 The adapted item asked, ‘Drive within 2 h of using cannabis in past 6 months?’ The frequency measure for this behaviour originally ranging from ‘Never’ to ‘10+ times’, was dichotomized into a yes/no response format. Mental and physical health functioning were based on the mental component score (MCS; α = .77) and physical component score (PCS; α = .71) of the Short Form‐12 Health Survey (SF‐12). 24 These two subscales measure individuals’ perceived impact of mental health and physical problems on daily activities. Standardized scores (t‐scores) were computed for both subscales ranging from 0 to 100, where higher scores indicate a higher level of functioning.
Data analysis
Statistical analyses and visualizations were performed in R version 4.3.1. 25 Our dependent variable was a binary (yes/no) past 6‐month WUIC behaviour. Demographic characteristics were computed using mean (standard deviation) and frequency (%) where ever appropriate. We performed univariate logistic regressions using the package stats. 26 For each model, a complete case analysis was employed; that is, respondents with any missing values were removed. Multivariable logistic regressions were also performed for each variable, adjusting for characteristics that were significant in univariate models, with the exception of average time using cannabis per week in the last 6 months due to redundancy with the average hours high per day. Significance in the present study is determined by the absence of ‘1’ in the 95% confidence interval of the odds ratio.
RESULTS
Table 1 displays descriptive information about participants' demographics, cannabis use, and other substance use characteristics. Participants were, on average, 41.14 (SD = 12.1) years old, and the majority were male (53.6%) and white (84.0%). At baseline, the majority (73.2%) reported using cannabis daily or almost daily in the past 6 months. The prevalence of those who endorsed ever WUIC in the past 6 months was 34.0% (N = 123). Figure 1 displays the proportion of respondents endorsing different classes of professions by WUIC history. WUIC in the past 6 months differed by classes of profession and was higher amongst those who work in Construction/Building/Repair and Operating Machinery/Power Tools, which are professions that may involve higher job‐related injury risks.
Table 1.
Sample descriptive of those who were employed in the past 6 months (N = 362).
| Total | No WUIC past 6‐months | WUIC past 6‐months | |
|---|---|---|---|
| N = 362 | N = 239 | N = 123 | |
| M (SD)/% (N) | M (SD)/% (N) | M (SD)/% (N) | |
| Age | 41.14 (12.04) | 43.25 (12.26) | 37.05 (10.48) |
| Female gender | 168 (46.4%) | 120 (50.2%) | 48 (39.0%) |
| Race | 194 (81.2%) | 112 (91.1%) | |
| White | 306 (84.0%) | 43 (18.0%) | 10 (8.1%) |
| Other race | 53 (14.6%) | 2 (0.8%) | 1 (0.8%) |
| Missing | 3 (0.8%) | ||
| Disability status | |||
| With disability | 16 (4.4%) | 9 (3.8%) | 7 (5.7%) |
| With no disability | 345 (95.3%) | 230 (96.2%) | 115 (93.5%) |
| Missing | 1 (0.3%) | 0 (0%) | 1 (0.8%) |
| SF12 Mental Health Componenta | 47.64 (10.63) | 47.69 (10.47) | 47.54 (10.97) |
| SF12 Physical Health Componenta | 35.30 (7.95) | 34.66 (7.65) | 36.53 (8.39) |
| Usual pain in the past month | 6.83 (1.33) | 6.87 (1.34) | 6.77 (1.30) |
| Past 6‐month drove within 2 h of cannabis use | |||
| Yes | 226 (63.7%) | 118 (50.6%) | 108 (88.5%) |
| No | 129 (36.3%) | 115 (49.5%) | 14 (11.5%) |
| History of medical cannabis card | |||
| Yes | 235 (64.9%) | 141 (59.0% | 94 (76.4%) |
| No | 129 (35.1%) | 98 (41.0%) | 29 (23.6%) |
| Past 6‐months cannabis use | |||
| Daily/Almost daily | 265 (73.2%) | 153 (64.0%) | 112 (91.1%) |
| Less than daily | 73 (20.2%) | 63 (26.4%) | 10 (8.1%) |
| Never | 24 (6.6%) | 23 (9.6%) | 1 (0.8%) |
| Average cannabis used per week in the past 30 days | |||
| Less than 0.5 oz | 253 (69.9%) | 185 (77.4%) | 68 (55.3%) |
| More than 0.5 oz | 97 (26.8%) | 46 (19.2%) | 51 (41.5%) |
| Missing | 12 (3.3%) | 8 (3.3%) | 4 (3.3%) |
| Number of hours high/day on cannabis | |||
| Less than 3 h | 169 (51.0%) | 125 (61.0%) | 44 (36.7%) |
| More than 3 h | 149 (45.8%) | 74 (36.1%) | 75 (62.5%) |
| Missing | 7 (2.2%) | 6 (2.9%) | 1 (0.8%) |
| Past 6‐months drug use | |||
| Yes | 49 (13.5%) | 30 (12.6%) | 19 (15.4%) |
| No | 313 (86.5%) | 209 (87.4%) | 104 (84.6%) |
| Past 6‐months episodes of 6+ drinks | |||
| Never | 124 (50.2%) | 86 (53.8%) | 38 (43.7%) |
| Less than monthly | 79 (32.0%) | 51 (31.9%) | 28 (32.2%) |
| Monthly or greater | 41 (16.6%) | 22 (13.8%) | 19 (21.8%) |
| Missing | 3 (1.2%) | 1 (0.6%) | 2 (2.3%) |
Scores range from 0 to 100, where a 0 score indicates the lowest level of health and 100 indicates the highest level of health.
Figure 1.
Prevalence of working under the influence of cannabis (WUIC) by types of professions (N = 362, participants were allowed to select multiple profession types).
Results of the logistic regressions evaluating the association of demographic characteristics with WUIC are summarized in Table 2. In univariate models, older age, female gender, and no history of medical cannabis certification card were associated with lower odds of WUIC. On the other hand, White race, better physical health, history of driving within 2 h of using cannabis in the past 6 months, 0.5 oz or more cannabis use per week in the past 30 days, and 3 or more hours high on cannabis per day were associated with higher odds of WUIC.
Table 2.
Unadjusted and adjusted results examining correlates of past 6‐month WUIC amongst those who were employed in the past 6 months (N = 362).
| Unadjusted odds ratio (95% CI) | Adjusted odds ratio (95% CI) | |
|---|---|---|
| Age (Ref. Mean)a | 0.96 (0.94, 0.97) *** | 0.95 (0.93, 0.98) *** |
| Female gender (Ref. Male gender)a | 0.63 (0.41, 0.99) ** | 0.66 (0.38, 1.15) |
| White race (Ref. Other race)a | 2.48 (1.25, 5.41) ** | 1.77 (0.76, 4.39) |
| Not Disabled (Ref. Disabled) | 0.64 (0.23, 1.84) | 0.34 (0.08, 1.34) |
| SF12 Mental Health Component (Ref. Mean) | 1.00 (0.98, 1.02) | 0.99 (0.96, 1.02) |
| SF12 Physical Health Component (Ref. Mean)a | 1.03 (1.00, 1.06) ** | 1.02 (0.98, 1.05) |
| Usual pain in the past month (Ref. Mean) | 0.95 (0.80, 1.12) | 1.06 (0.85, 1.34) |
| Past 6‐month DUIC (Ref. No DUIC)a | 7.52 (4.19, 14.41) *** | 4.64 (2.29, 9.58) *** |
| No medical cannabis card (Ref. Current medical cannabis card)a | 0.44 (0.27, 0.72) *** | 0.62 (0.33, 1.16) |
| Past 30 days 0.5 oz+ cannabis used per week (Ref. Less than 0.5 oz.)a | 3.02 (1.86, 4.92) *** | 1.89 (1.04, 3.48) ** |
| 3+ hours of high per day on cannabis (Ref. Less than 3 h)a | 2.88 (1.81, 4.64) *** | 2.08 (1.20, 3.63) ** |
| Past 6‐month other substance use (Ref. No other substance use)a | 1.27 (0.68, 2.35) | 1.51 (0.67, 3.38) |
| Past 6‐month episodes of 6+ drinks | ||
| Less than monthly (Ref. Never) | 1.24 (0.68, 2.26) | 0.40 (0.17, 0.91) * |
| Monthly or greater (Ref. Never) | 1.95 (0.95, 4.04) | 0.84 (0.31, 2.25) |
Note: Bold values indicate statistically significant at p < .01.
Abbreviations: CI, confidence interval; DUIC, driving under the influence of cannabis use; Ref., reference group.
Adjusted for in the adjusted logistic regressions.
p < .001
p < .05
p < .01.
After adjusting for significant univariate associations, older age remained significantly associated with lower odds of WUIC; driving within 2 h of using cannabis in the past 6 months, reporting three or more hours high on cannabis per day, and consuming 0.5 oz or more of cannabis per week in the past 30 days remained significantly associated with higher odds of WUIC. In addition, having episodes of six or more drinks compared to never having six or more drink episodes in the past 6 months became statistically significant (p < .01) in the adjusted model.
DISCUSSION
In the present study, approximately a third of medical cannabis patients with chronic pain who were in the workforce reported WUIC. In light of cannabis policies expanding legal access to cannabis for medical use and given the potential risks of impaired psychomotor skills and cognitive ability from cannabis use, these findings underscore the need for improved data on the extent and consequences of cannabis use in the workforce amongst those who use cannabis for medical reasons. Given the cognitive and physical impairment associated with acute cannabis use 7 , 11 it is possible that cannabis use may be associated with injury in the workplace. The present study provides an important initial step towards understanding WUIC amongst workers who consume cannabis medically for chronic pain in the state of Michigan. In addition, research on the association between cannabis use and occupational safety and health needs to be explored across different populations, occupations, workplace settings, worker characteristics, and work patterns. For instance, our exploratory analyses showed that WUIC in the past 6 months differed by classes of professions and was particularly common in certain professions (i.e., Construction/Building/Repair and Operating Machinery/Power Tools) that may involve higher job‐related risks. By understanding the occupations and industries of workers who report medical cannabis use, employers can develop appropriately targeted workplace cannabis policies and safety measures. In addition, other more‐subtle acute effects of cannabis on concentration and cognition could still be important for outcomes like productivity and advancement, which remain largely unexplored in the literature.
In unadjusted analyses, older age, female gender, not having a pre‐existing medical cannabis card (as compared to obtaining one again), and using cannabis less than daily per week, as well as more opioid misuse were significantly associated with lower odds of WUIC. The present analyses could not specifically examine the timing of co‐use of substances but the general association between other measures of drug use and WUIC underscores the importance of examining the potential impact of using multiple substances on workplace activities. Also, higher pain severity was associated with decreased odds of WUIC in an unadjusted model. This may be due to individuals experiencing higher levels of pain being less likely to engage in the workforce or to use cannabis at work for pain management. Key areas for further investigation would be to examine how increased levels of pain impact the selection of occupation as well as the context of cannabis use at work.
There are some limitations to consider with this study, including the cross‐sectional nature of the analyses and the retrospective self‐reported assessments used, precluding causal interpretations. In addition, some of the measures, including measures of duration of cannabis effects and quantity of cannabis consumption, were developed for the original project, and the psychometric properties are unknown. Also, the main outcome, WUIC, was measured using a compound question (i.e., been high or used marijuana on your job), and future work should include separate items assessing these two domains. This may lead to underestimation of the time course and extent of cannabis‐related effects. Our study results may not generalize to other populations, given that the data came from employed medical cannabis patients with chronic pain living in the state of Michigan. Relatedly, it is plausible that some prospective participants may have declined to provide consent for reasons unrelated to the study's objectives, such as concerns about inadequate compensation potentially introducing selection bias in our study sample. These factors could potentially affect the generalizability of the study findings. Future research could be improved by collecting nationally representative data on WUIC to provide additional knowledge such as parallel comparisons regarding whether the current sample engages in WUIC more or less frequently than, for example, those who use cannabis recreationally.
Even with these limitations, this is the first study of which we are aware to examine WUIC in a medical cannabis patient context. The results indicate a potential need for interventions to increase medical cannabis patients' understanding of cannabis‐related impairment at work as well as to examine how individuals with medical cannabis balance the potential medical benefits of cannabis use with other aspects of their lives, namely, working. A greater understanding of WUIC within different employment settings amongst people who consume cannabis for medical reasons is needed, particularly in light of rapidly evolving state‐level policies increasing access to legal medical and recreational cannabis.
CONFLICT OF INTEREST STATEMENT
The authors declare no conflicts of interest.
ACKNOWLEDGEMENTS
Drs. Lee & Tomlinson's time was supported by a grant from the NIAAA T32 007477. Dr. Ilgen's time was partially supported by VA RCS 19‐333.
Lee CA, Tomlinson DC, Bohnert KM, Bonar EE, Coughlin LN, Ilgen MA. Working under the influence of cannabis amongst medical cannabis patients with chronic pain. Am J Addict. 2025;34:415‐421. 10.1111/ajad.70028
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