Medical Cannabis Program Resilience in the Era of Adult-Use Cannabis Legalization: A Tale of Three Medical Programs

Julie Johnson, Alexander Colby and Graelyn Humiston – Cannabis Control Commission

Abstract

Aim: To assess medical program activity in three U.S. states after the enactment of adult-use legalization and implementation of retail stores to better understand medical program sustainability alongside adult-use legalization.

Background:

As of October 2023, 23 U.S. states have legalized adult-use cannabis, with 20 of these states having both medical and adult-use cannabis retail establishments (“retailers”). While adult-use retailers provide safe access to the general population for cannabis use, medical programs often present safer, more affordable, and more diverse product options for patients’ unique medical needs. Despite the importance of medical programs, growing evidence suggests that medical program activity decreases following adult-use retail implementation (i.e., adult-use market preeminence). This decreased activity suggests a decreased sustainability of these programs after adult-use implementation, which may be highly detrimental to patients who are more likely to be low-income, older, and in poorer health than the general population. To better serve medical patients, it is critical for medical programs to be designed for sustainability and operationalized alongside adult-use programs to ensure these programs do not become artifacts of adult-use cannabis legalization.

Methods:

We conducted a quasi-experimental, cross-sectional study using cannabis regulatory data to compare outcomes in three states with both medical and adult-use cannabis programs and retailers (Colorado, Massachusetts, Oregon). Linear regression analyses were conducted to assess three outcome measures: 1) medical-use retail sales, 2) adult-use retail sales, and 3) number of registered medical patients in all fiscal quarters after adult-use retail sales were implemented in each state to September 2022.

Results:

Medical program sales and patient registrations only increased in Massachusetts despite adult-use sales increasing in all three states after adult-use retail was implemented. Over the time since implementation, medical sales were not available for Oregon and decreased non-significantly in Colorado, while patient registrations decreased significantly in both Colorado and Oregon. Over the first three years of adult-use retail, patient registrations dropped by 22% in Colorado and 55% in Oregon but increased by 51% in Massachusetts.

Conclusions:

Study results indicate that medical cannabis programs undergo critical changes after the implementation of adult-use retail store policy provisions. Data demonstrates that medical cannabis markets are not inherently dismantled by the co-operating of adult-use markets. Rather, results suggest that specific aspects (i.e., provisions, priorities, functionality) of a medical program assist in its sustainability, a phenomenon that additional research may help isolate for future policy. Key policy differences, such as program design and regulatory differences in the implementation of adult-use sales, may have differential impacts on medical programs. For continued patient access, it is critical that future research assesses the differences within and between states’ medical-use and adult-use program design (i.e., policy and regulation) that permit medical program sustainability alongside adult-use legalization and implementation.