Data shows medical marijuana use decreased in states where recreational use became legal 

Embargoed for release until 5:00 p.m. ET on Monday 8 April 2024    
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Below please find summaries of new articles that will be published in the next issue of Annals of Internal Medicine. The summaries are not intended to substitute for the full articles as a source of information. This information is under strict embargo and by taking it into possession, media representatives are committing to the terms of the embargo not only on their own behalf, but also on behalf of the organization they represent.    
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1. Data shows medical marijuana use decreased in states where recreational use became legal  

Abstract: https://www.acpjournals.org/doi/10.7326/M23-2811    

URL goes live when the embargo lifts      

The most up-to-date data on registered medical cannabis use found that enrollment in medical cannabis programs increased overall between 2016 and 2022, but enrollment in states where nonmedical use of cannabis became legal saw a decrease in enrollment. Combined with the data from a previously published analysis, the number of patients using cannabis for medical purposes has increased more than 600 percent since 2016. The study is published in Annals of Internal Medicine.  

Cannabis is legal for medical or nonmedical adult use in 38 and 23 states, respectively. However, it remains a schedule I substance under the Controlled Substances Act. This status has inhibited research on its health effects and disincentivized many physicians from pursuing education related to or treating patients who use cannabis. Recently, the Department of Health and Human Services recommended that cannabis be rescheduled to schedule III. Before this potential shift occurs, it is important to understand the current landscape of medical and nonmedical cannabis use and authorization.  

Researchers from University of Michigan Medical School and the Centers for Disease Control and Prevention conducted an ecological study with repeated measures of persons with medical cannabis licenses and clinicians authorizing cannabis licenses in the United States between 2020 and 2022. The authors included 39 jurisdictions (38 states and Washington, D.C.) that allowed for medical cannabis use in their analysis. Of these jurisdictions, 34 reported patient numbers, 19 reported patient-reported qualifying conditions, and 29 reported authorizing clinician numbers. Overall, they reported a 33 percent increase in patient enrollment in these jurisdictions between 2020 (3.1 million) and 2022 (4.1 million). However, within the 15 jurisdictions with active adult use laws, 13 had decreasing enrollment. From 2020-2022, the proportion of patient-reported qualifying conditions with substantial or conclusive evidence of therapeutic value decreased from 70.4 to 53.8 percent. The most reported qualifying condition was chronic pain, followed by anxiety and post-traumatic stress disorder. The authors report that there were 29,500 clinicians who authorized medical cannabis in 2022, and the most common specialty of these clinicians was internal or family medicine. According to the authors, their findings highlight the need for better surveillance methods to adequately understand outcomes of medical cannabis use and thoughtful strategies and public health efforts to reduce harms from increased cannabis availability. 

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author, Kevin F. Boehnke, PhD, please email kboehnke@med.umich.edu.

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2. Salt substitution associated with lower risk for all-cause, cardiovascular mortality

Abstract: https://www.acpjournals.org/doi/10.7326/M23-2626   

Editorial: https://www.acpjournals.org/doi/10.7326/M24-0860   

URL goes live when the embargo lifts     

A systematic review of 16 randomized controlled trials found that the use of a salt substitute in food preparation was associated with a lower risk for both all-cause and cardiovascular mortality. The analysis is published in Annals of Internal Medicine.

Cardiovascular disease is the leading cause of death globally, and its onset is associated with high dietary sodium intake. Despite calls from organizations like the World Health Organization for people worldwide to reduce sodium intake, global sodium consumption still exceeds the recommended daily limit. Substituting table salt with a substitute containing reduced sodium and increased potassium may be a minimally invasive, achievable strategy to reduce sodium intake.

Researchers from Bond University, Queensland, Australia, conducted a systematic review and meta-analysis of 16 randomized controlled trials (RCTs) of persons using regular table salt or salt substitutions for at least six months. They found that salt substitution may reduce all-cause or cardiovascular mortality, but the evidence for reducing cardiovascular events and for not increasing serious adverse events is uncertain. The authors found that 8 of the 16 included RCTs studied primary outcomes. Of these, 7 studies occurred in China or Taiwan. Additionally, 7 of the 16 studies included older persons, who are at higher risk for cardiovascular disease. Because of these factors, generalizability to a population with an average cardiovascular disease risk or eating a Western diet is limited.

An accompanying editorial by authors from the University of Sydney, University of California San Diego, and University of New South Wales highlights the lack of changes made by governments and the global food production history to tackle the World Health Organization’s recommendations to reduce worldwide sodium consumption by 30 percent by 2025. The authors suggest that the widespread use of salt substitutions provide an achievable, accessible means to reaching that goal for the global food production industry.  

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author,  Loai Albarqouni, MD, MSc, PhD, please contact lalbarqo@bond.edu.au.

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3. Resistance training no better than neuromuscular exercise in persons with hip osteoarthritis  

Abstract: https://www.acpjournals.org/doi/10.7326/M23-3225    

URL goes live when the embargo lifts      

A study of persons with hip osteoarthritis (OA) found no difference between progressive resistance training (PRT) and neuromuscular exercise (NEMEX) for improving functional performance, hip pain, or hip-related quality of life. The study is published in Annals of Internal Medicine.  

High-quality evidence has shown that exercise is effective in reducing pain and improving physical function in hip OA, and clinical guidelines recommend exercise as first-line treatment. NEMEX and PRT are both exercise programs meant to improve pain, physical function, and quality of life in persons with hip OA. However, there is limited evidence comparing any exercise programs or establishing optimal exercise content or dosage in persons with hip OA.  

Researchers from Aarhus University Hospital, Aarhus, Denmark, conducted a multicenter cluster randomized controlled trial of 160 persons with hip OA. Eighty-two participants were randomly assigned to PRT and 78 were assigned to NEMEX for 12 weeks. The PRT intervention consisted of 5 high-intensity resistance training exercises targeting muscles at the hip and knee joints. The NEMEX intervention included 10 exercises and emphasized sensorimotor control and functional stability. The authors found that there were no clinically relevant differences in outcomes between groups. However, the authors noted a slightly larger improvement in muscle strength and power for participants undergoing PRT and suggest that PRT may be a better option for patients who present with muscle weakness or are at risk for developing sarcopenia. 

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author, Troels Kjeldsen, MSc, please contact tkjeldsen@clin.au.dk.  

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4. Physicians debate best management strategy for patient at risk for HIV exposure 

‘Beyond the Guidelines’ features are based on the Department of Medicine Grand Rounds at Beth Israel Deaconess Medical Center 

Abstract: https://www.acpjournals.org/doi/10.7326/M24-0217    

URL goes live when the embargo lifts      

In a new Annals ‘Beyond the Guidelines’ feature, two physicians experienced in HIV antiretroviral pre-exposure prophylaxis (PrEP) debate how best to identify those patients who might benefit from PrEP, how to decide what regimen to use, and how to monitor therapy. All ‘Beyond the Guidelines’ features are based on the Department of Medicine Grand Rounds at Beth Israel Deaconess Medical Center (BIDMC) in Boston and include print, video, and educational components published in Annals of Internal Medicine.   

Despite advances in treatment, HIV infection remains an important cause of morbidity and mortality, and more than 30,000 new cases are diagnosed in the United States each year. Several interventions have traditionally been used to prevent HIV transmission, but these vary in effectiveness, and there are challenges in their implementation. Both the CDC and the USPSTF strongly recommend the use of HIV PrEP for persons at risk. However, the implementation of PrEP in clinical practice has been variable, especially among patients underserved by the medical system and marginalized by society. Fewer than one-third of persons in the United States who are eligible for PrEP currently receive it. 

BIDMC Grand Rounds discussants, Douglas Krakower, MD, Associate Professor of Medicine at Harvard Medical School and a member of the Division of Infectious Diseases at Beth Israel Deaconess Medical Center and Jessica L. Taylor, MD, Assistant Professor of Medicine at Boston  University School of Medicine and Medical Director of Faster Paths to Treatment at Boston Medical Center,  recently debated the case of Ms. S, a 30 year-old woman with substance use disorder who is at risk for HIV infection and has intermittently received PrEP.  

In his assessment, Dr. Krakower recommends that Ms. S receive PrEP given her high risk for HIV infection. He also recommends injectable cabotegravir because of psychosocial challenges interfering with persistent daily pill use. Dr. Taylor recommends that Ms. S should be offered PrEP where she already accesses addiction treatment, harm reduction, and other services. She recommends that Ms. S receive daily oral TDF/FTC, as it is the only medication with evidence for HIV prevention among both people who inject drugs and people at risk via vaginal sex. Dr. Krakower believes that robust support from an interprofessional health care team would be essential to maintain adherence to any PrEP method. In addition, he would recommend counseling on safer sexual and injection behaviors, as well as treatment of HCV infection after resolution of her acute medical issues. Dr. Taylor suggests that in the future, a switch to cabotegravir could be considered, acknowledging the gaps in evidence for parenteral exposure. She also recommends other HIV prevention interventions, including continued methadone treatment, provision of condoms and sterile injection equipment, and the availability of STI testing and treatment, should be optimized. 

A complete list of ‘Beyond the Guidelines’ topics is available at www.annals.org/grandrounds. 

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. For an interview with the discussants, please contact Kendra McKinnon at kmckinn1@bidmc.harvard.edu.