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. Author manuscript; available in PMC: 2021 Jul 1.
Published in final edited form as: Drug Alcohol Depend. 2020 May 15;212:108035. doi: 10.1016/j.drugalcdep.2020.108035

Cannabis use prevalence among individuals with diabetes The National Survey on Drug Use and Health, 2005–2018 Short Communications

Trevor R Sexton a, Omayma Alshaarawy b
PMCID: PMC7293923  NIHMSID: NIHMS1594719  PMID: 32470752

Abstract

Background:

The aim of the current study is to estimate cannabis use prevalence among individuals with diabetes participating in the United States (US) National Survey on Drug Use and Health (NSDUH), 2005–2018. Plausible biological mechanisms link cannabis use and metabolic regulation. Cannabis use can also alter perception and adherence to treatment especially among patients with insulin-dependent diabetes.

Methods:

The NSDUH is designed to select and recruit, annually, a representative sample of the non-institutionalized US population (12+ years). Computer-assisted self-interviews gathered information on cannabis use. The current study sample included 30915 participants who self-reported a physician diagnosis of diabetes.

Results:

Prevalence of past 30-day cannabis use increased 340% among individuals with diabetes, from 1.7% (95% confidence interval [CI] = 1.1, 2.6) in 2005 to 5.8% (95% CI = 4.7, 7.1) in 2018. Results from the logistic regression model indicated that this increase was robust (odds ratio of cannabis use per NSDUH year = 1.13; 95% CI = 1.10, 1.15). The increase was observed among different sociodemographic subgroups and in states with or without medical cannabis laws.

Conclusions:

As cannabis use prevalence increases, screening for use among diabetes patients is needed to optimize outcomes and reduce potential adverse effects.

Keywords: Cannabis, Diabetes, Prevalence, NSDUH, Trends

1. Introduction

In the United States (US), cannabis is legalized for recreational use for adults 21 years and older in 11 states and the District of Columbia, and 33 states have legalized the use of cannabis for medical purposes (National Conference of State Legislatures, 2020). Benefits and adverse health effects of cannabis use have been long debated, especially the effects of cannabis use in patients with underlying medical conditions. There is not sufficient evidence available for healthcare providers and patients to make an informed decision regarding cannabis use (Volkow et al., 2014). Yet, recent research suggest that cannabis use is more common among adults with medical conditions compared to those who are free from such conditions (Dai and Richter, 2019).

The aim of the current study is to evaluate cannabis use trends among individuals with diabetes. In 2018, an estimated 34.2 million people (10.5% of the US population) had diabetes (Center for Disease Control and Prevention, 2020). Pre-clinical research supports a possible role of cannabis in metabolic regulation (Sidney, 2016). Because of its appetite-stimulating effects, cannabis is used to enhance food intake and weight gain in patients with cachexia (Whiting et al., 2015). In pre-clinical studies and in human laboratory studies, cannabinoid administration was associated with significant changes in blood concentrations of hormones involved in glucose regulation, mainly insulin (Kim et. al. 2011; Farokhnia et al. 2020). Epidemiological studies have reported either an inverse association or no association between cannabis use, and weight gain, fasting insulin, and type 2 diabetes mellitus prevalence (Alshaarawy and Anthony 2015; Alshaarawy and Anthony, 2019; Bancks et al., 2015; Jin et al., 2017; Penner et al., 2013).

In addition, the evidence for whether cannabis use has beneficial or adverse effects in diabetes patients remains inconclusive. Type 1 diabetes patients who used cannabis had a higher prevalence of diabetic ketoacidosis compared to non-using patients (Akturk et al., 2019), whereas pre-clinical experimental work has suggested that cannabis can reduce diabetes complications including retinopathy and neuropathy (Horváth et al., 2012).

Given the increasing number of states legalizing cannabis, the increased social acceptance of its use (Carliner et al., 2017), and the possible impact of cannabis on glucose metabolism, it is imperative for healthcare providers to understand use patterns among individuals with diabetes. In this paper, we analyze data from a large national survey to estimate recent cannabis use prevalence among individuals with diabetes in US community residents from 2005–2018.

2. Methods

The National Survey on Drug Use and Health (NSDUH, 2005–2018) is a series of annual cross-sectional surveys designed to select a nationally representative of the US civilian non-institutionalized population aged 12 years and older (United States, 2016). The response rate for NSDUH has declined across the years (Substance Abuse and Mental Health Services Administration. 2019). For each NSDUH year, the weighted screening response rate was > 73%, the weighted interview response rate was > 66%, and the overall response rate (defined as the product of the weighted screening response rate and weighted interview response rate) was > 48 %. The institutional review board at Michigan State University ruled this study as exempt because data used were from de-identified files made available for public use.

Audio computer-assisted self-interview system (ACASI) assessed cannabis use in a private location at or near the participant residence. Here, cannabis use was defined as using cannabis at least once in the 30 days prior to NSDUH interview. During the ACASI, participants were asked whether a doctor or health care professional had ever told them that they had diabetes. The study analytic sample consisted of participants who answered ‘Yes’ to this question (n = 30915). Logistic regression was used to regress cannabis use as the response variable on NSDUH year indicator as the main exposure (continuous variable) controlling for variables associated with cannabis use such as age, sex, race/ethnicity, education, and total family income. The NSDUH variance estimation variables (VESTR and VEREP) and final analysis weight (ANALWT_C) were used in all analyses using Stata Svy commands (version 15, StataCorp).

3. Results

The annual number of participants with diabetes ranged from 1537 to 3147 across NSDUH 2005–2018 (Figure 1) whereas the weighted prevalence of diabetes ranged from 6.8% to 10.1% consistent with other US national data sources (Pemberton et al., 2012). Across 2005–2018, an estimated 76% of US individuals with diabetes were 50 years and older, 52% were females, 62% were non-Hispanic White, 79% had high school education or more and 59% had a total family income <$50000. From 2005 to 2018, there were no changes in sex and race composition of the study population, whereas age (increase in 50+ subgroups), education (increase in > high school subgroup), and total family income (increase in $75000+ subgroup) composition changed over time (Data are not shown in table/figure).

Figure 1:

Figure 1:

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Prevalence of past 30-day cannabis use among individuals with diabetes. Data for the US National Survey on Drug Use and Health, 2005–2018.

a Weighted prevalence estimates are presented adjusted for NSDUH complex survey design. Horizontal bars represent 95% CI.

The prevalence of past 30-day cannabis use has increased among individuals with diabetes from 1.7% in 2005 (95% confidence interval [CI] = 1.2, 2.6), to 5.8% in 2018 (95% CI = 4.7, 7.1, Figure 1). Results from the logistic regression model indicated that this increase was robust (odds ratio [OR] of cannabis use per NSDUH year = 1.11; 95% CI = 1.09, 1.13, Table 1). Adjusting for age, sex, race/ethnicity, education or income minimally affected the estimates (OR = 1.13; 95% CI = 1.10, 1.15).

Table 1:

Odds ratios per NSDUH year indicating trends in past 30-day cannabis use among individuals with diabetes. Data for the US National Surveys on Drug Use and Health 2005–2018.

Variable (unweighted n) Prevalencea % (95% Cl) Crude OR per NSDUH yearb (95% Cl) Multivariable-adjusted OR per NSDUH yearc (95% Cl)
Survey year, all sample (30915) 3.2 (2.9, 3.4) 1.11 (1.09, 1.13) 1.13 (1.10, 1.15)
Subgroup analyses
Age
12–21 years (3128) 12.6 (10.9, 14.5) 1.05 (1.01, 1.09) 1.05 (1.01, 1.09)
22–34 years (4144) 10.5 (9.2, 11.9) 1.09 (1.05, 1.14) 1.10 (1.06, 1.15)
35–49 years (7985) 4.7 (4.2, 5.3) 1.08 (1.04, 1.12) 1.10 (1.06, 1.14)
50–64 years (8000) 3.4 (2.9, 4.0) 1.14 (1.10, 1.19) 1.15 (1.10, 1.20)
65+ years (7658) 0.8 (0.6, 1.1) 1.24 (1.12, 1.37) 1.23 (1.12, 1.36)
Sex
Male (13603) 3.7 (3.4, 4.1) 1.10 (1.07, 1.13) 1.12 (1.09, 1.15)
Female (17312) 2.7 (2.4, 3.0) 1.12 (1.08, 1.16) 1.13 (1.09, 1.17)
Race/ethnicity
Non-Hispanic White (18404) 3.3 (3.0, 3.6) 1.11 (1.08, 1.14) 1.13 (1.10, 1.16)
Non-Hispanic Black (4846) 3.6 (3.1, 4.3) 1.09 (1.04, 1.14) 1..0 (1.06, 1.15)
Hispanic (4868) 2.5 (1.9, 3.2) 1.13 (1.07, 1.19) 1.14 (1.08, 1.21)
All others (2797) 2.4 (1.9, 3.1) 1.10 (1.01, 1.20) 1.11 (1.01, 1.21)
Education
< High school (7552) 2.9 (2.5, 3.3) 1.10 (1.06, 1.14) 1.11 (1.07, 1.15)
High school (9583) 3.0 (2.6, 3.4) 1.10 (1.05, 1.13) 1.11 (1.06, 1.16)
> High school (13780) 3.4 (3.0, 3.8) 1.12 (1.09, 1.16) 1.14 (1.11, 1.18)
Family income
<$20000 (7751) 4.5 (3.9, 5.2) 1.11 (1.07, 1.15) 1.12 (1.07, 1.16)
$20000-$49999 (11296) 3.1 (2.7, 3.6) 1.13 (1.09, 1.17) 1.14 (1.10, 1.19)
$50000-$74999 (4849) 2.3 (1.9, 2.8) 1.06 (0.99, 1.14) 1.09 (1.02, 1.16)
$75000+ (7019) 2.6 (2.2, 3.0) 1.11 (1.05, 1.17) 1.12 (1.07, 1.18)
Age at diagnosisd
< 20 years (2087) 11.2 (9.4, 13.2) 1.16 (0.97, 1.40) 1.21 (1.00, 1.46)
≥ 20 years (9773) 4.1 (3.6, 4.7) 1.18 (1.04, 1.34) 1.21 (1.06, 1.37)
Living in a state with medical cannabis lawe
Yes (8302) 5.5 ‘4.9, 6.2) 1.15 (1.07, 1.25) 1.16 (1.07, 1.27)
No (8428) 2.8 (2.4, 3.2) 1.14 (1.05, 1.24) 1.14 (1.05, 1.24)
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a

Weighted prevalence estimates are presented adjusted for NSDUH complex survey design

b

NSDUH year indicator is modelled as a continuous variable. Crude ORs are presented, adjusted only for NSDUH complex survey design. Each row reprent a separate regression model.

c

ORs are adjusted for the following variables except when the stratified estimates are presented for the specific variable: age, sex, race/ethnitiy, education and total family income. Each row reprent a separate regression model.

d

Results are presented for NSDUH 2015–2018. Data on age of diabetes diagnosis are not available in 2005–2014. There were 337 participants with diabetes in NSDUH 2015–2018, for which the age of diagnosis is not known.

e

Results are presented for NSDUH 2013–2018. Data on medical cannabis laws are not available in 2005–2012.

In the pooled NSDUH 2005–2018, cannabis use prevalence was lower among individuals with diabetes compared to individuals without diabetes (3.2% vs. 7.9%, multivariable-adjusted OR for past 30-day cannabis use for individuals with diabetes = 0.66; 95% CI = 0.61, 0.71, data are not shown in table/figure). Among individuals with diabetes, past 30-day cannabis use was more prevalent among the younger age groups, males, participants with a total family income <$20000 and participants living in a state in which a law allowing cannabis use for medical reasons was in effect/passed at the time of NSDUH interview (Table 1). Yet, the increase in cannabis use prevalence was observed across all age, sex, race/ethnicity, education and income subgroups. Stratifying by age of diabetes diagnosis did not disclose robust differences between those who were diagnosed when <20 years of age or those who were diagnosed when ≥ 20 years of age.

The prevalence of cannabis use increased in states with or without medical cannabis laws. Among those who used cannabis in the past 30-days, approximately 78% used cannabis that was not prescribed by a doctor or healthcare professional in the past 12 months, whereas 14% used cannabis that was solely prescribed (Data are not shown in figure/table).

4. Discussion

We demonstrated that cannabis use prevalence has increased among individuals with diabetes from 2005–2018. The increase in cannabis use prevalence was observed in states with or without medical cannabis laws. Stratifying by age, sex, race/ethnicity, education, total family income and age of diabetes diagnosis did not disclose robust subgroup variations. The increase in cannabis use among age groups where diabetes is more prevalent (50+ years) might be explained by the aging cohorts with increasing cannabis use prevalence rates as well as increasing survival owing to improvements in diabetes management (Han et al., 2017; Han and Palamar, 2020; Maruthur, 2013).

Strengths of the study include the large nationally representative sample and the use of standardized and well-implemented methods for data collection. Limitations of the study include the reliance on self-report with no bioassays to confirm cannabis use status. Hence, we cannot confirm if the estimated increase is due to a substantial increase in cannabis use, or due to an increase in reporting owing to the changing cannabis landscape (Hasin et. al., 2018). For each NSDUH year, the medical cannabis law variable is based the question of whether the participant lives in a state in which a law allowing cannabis use for medical reasons was in effect/passed at the time of NSDUH interview. Accordingly, NSDUH does not capture changes in medical cannabis laws beyond the time of the interview.

Diabetes status was also self-reported and the NSDUH question on diabetes does not specify diabetes type. In addition, the question on diabetes does not include a distinction for gestational diabetes, suggesting that the current study sample size might be lower if this exclusion has been specified. This limitation, however, is unlikely to change the study conclusions since the increasing trend was robust in men and in age groups where gestational diabetes is uncommon.

In addition, starting 2015, some changes were made to NSDUH survey questionnaire. Questions did not change for cannabis to permit measurement of trends in use. A new question asking about age of first diagnosis of diabetes was added which might have affected our sample size. Nevertheless, the increase in cannabis use among individuals with diabetes was observed when analyzing NSDUH years prior to the change (2005–2014, multivariable-adjusted OR for each NSDUH year = 1.10; 95% CI = 1.06, 1.14) and NSDUH years after the change separately (2015–2018, multivariable-adjusted OR for each NSDUH year = 1.20; 95% CI = 1.07, 1.34).

In summary, cannabis use has increased 340% (1.7% to 5.8%) among US individuals with diabetes from 2005–2018. Physicians should be aware of the increasing prevalence of cannabis use and how it may affect the care of diabetes patients and may need to inquire about cannabis use as a regular portion of the diabetes workup. Physicians should educate patients about cannabis use, including its effects on appetite, gastric emptying and its effects on the patient’s perception of reality and, thus, potentially treatment adherence, which can be crucial in the management of insulin dependent diabetes.

Highlights.

  • We observed a 340% increase in cannabis use prevalence among NSDUH participants with diabetes.

  • The increase was observed among different sociodemographic subgroups and in states with or without medical cannabis laws

  • Physicians need to be aware of the increasing trend and how cannabis use can affect glucose regulation.

Role of Funding Source

The study was funded by the NIH/NCCIH R00AT009156 and by Michigan State University. The funding body had no role in the design of the study, collection and analysis of data or the decision to publish. The content is the sole responsibility of the authors and does not represent the official views of Michigan State University or the National Institutes of Health.

Footnotes

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Conflict of Interest

Both authors declare that they have no conflicts of interest.

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