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The Increasing Use of Cannabis Among Older Americans:
APublic Health Crisis or Viable Policy Alternative?
BrianKaskie, PhD,* PadmajaAyyagari, PhD, GaryMilavetz, PharmD, DanShane, PhD,
and KanikaArora, PhD
Department of Health Management and Policy, College of Public Health, University of Iowa.
*Address correspondence to Brian Kaskie, PhD, Department of Health Management and Policy, College of Public Health, University of Iowa,
105N River Street, N214, Iowa City, IA 52242. E-mail: firstname.lastname@example.org
Received June 7, 2016; Editorial Decision date October 11, 2016
Decision Editor: John B.Williamson, PhD
Cannabis use among older Americans is increasing. Although much of this growth has been attributed to the entry of a
more tolerant baby boom cohort into older age, recent evidence suggests the pathways to cannabis are more complex.
Some older persons have responded to changing social and legal environments and are increasingly likely to take cannabis
recreationally. Other older persons are experiencing age-related health care needs, and some take cannabis for symptom
management, as recommended by a medical doctor. Whether these pathways to recreational and medical cannabis are sepa-
rate or somewhat tangled remains largely unknown. There have been few studies examining cannabis use among the grow-
ing population of Americans aged 65 and older. In this essay, we illuminate what is known about the intersection between
cannabis and the aging American population. We review trends concerning cannabis use and apply the age–period–cohort
paradigm to explicate varied pathways and outcomes. Then, after considering the public health problems posed by those
who misuse or abuse cannabis, we turn our attention to how cannabis may be a viable policy alternative in terms of sup-
porting the health and well-being of a substantial number of aging Americans. On the one hand, cannabis may be an
effective substitute for prescription opioids and other misused medications; on the other hand, cannabis has emerged as an
alternative for the undertreatment of pain at the end of life. As intriguing as these alternatives may be, policy makers must
rst address the need for empirically driven, representative research to advance the discourse.
Keywords: Alternative and complementary medicine/care/therapy, Health care policy, Medications/prescriptions/OTC drugs/pharmacol-
ogy, Pain management, Public policy
Cannabis use among persons older than 50 years has
increased signicantly, exceeding projections and out-
pacing the recent growth observed across all other age
groups (Substance Abuse and Mental Health Services
Administration, 2014). In 2000, past-year cannabis use
among all persons older than 50 years was estimated as
1.0%, with rates reaching 2.0% among those aged between
50 and 59years (i.e., the baby boomers). Projecting to the
year 2020, use rates among those older than 50years were
expected to climb to 2.9%, largely as a function of the
continued aging of a baby boom cohort with historically
higher rates of lifetime use (Colliver, Compton, Gfroerer,
& Condon, 2006). However, when analyzing the 2008
National Survey of Drug Use and Health (NSDUH),
DiNitto and Choi (2011) found past-year cannabis use for
all persons older than 50years already had reached 2.8%.
When NSDUH data from 2008 through 2012 were pooled,
Choi, DiNitto, Marti, and Choi (2015) found past-year
cannabis use climbed to 3.9%.
Using another nationally representative survey, the 2014
Summer Styles Consumer Panel Survey, Schauer, King,
Bunnell, Promoff, and McAfee (2016) found that 5.1% of
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Advance Access publication January 11, 2017
Copyedited by: SU
persons older than 50 years reported taking cannabis in
the past month, suggesting use rates might be higher than
indicated by the NSDUH data. Schauer and colleagues
(2016) also reported that among all current cannabis users
(including those older than 50 years), 10.5% reported
medicinal-only use, 53.4% reported recreational-only use,
and 36.1% reported both. In comparison to the NSDUH,
these estimates were generated from a small subpopulation
of older adults who were not recruited from a population-
based probability sample. Schauer and colleagues also did
not stratify reasons for use by age (Figure1).
Although this prior work has been illuminating, policy
makers have only been offered glimpses into this imminent
public health challenge. Several substantive gaps exist in
what is currently known about cannabis and older persons.
What are the self-reported antecedents of taking cannabis?
Does cannabis use lead to substance misuse or prescrip-
tion substitution? As the United States is about to enter a
period when the older adult population is projected to dou-
ble (Ortman, Velkoff, & Hogan, 2014) and the cannabis
economy may grow vefold (Caulkins, Kilmer, Reuter, &
Midgette, 2015), such critical questions need to be asked.
Yet, at this time, there have been few directions charted for
conducting the kind of research that would be most useful
in providing empirically based answers.
In this analytic essay, we apply the age–period–cohort par-
adigm to explore the intersection between cannabis and older
persons. We consider how cannabis use among older adults
is being shaped variably by social attitudes, state laws, and
individual characteristics, such as health needs and prescrip-
tion drug use, and rely on previous data analyses as well as
original data collected from eight state medical cannabis pro-
grams to chart the different paths older adults are taking. We
consider undesirable outcomes such as the misuse and abuse
of cannabis. We then direct our attention to two other promi-
nent public health issues, one concerning the increasing mis-
use of prescription medications (e.g., opioids) and the other
focusing on the undertreatment of pain at the end of life, and
consider how cannabis substitution may be a viable policy
alternative to these more prominent public health problems.
Antecedents of Cannabis Use Among Persons
Older Than 50Years
The majority of persons older than 50years who currently
take cannabis are healthy and white, though there are sev-
eral signicant individual differences among the population
of nearly 45 million older Americans (Choi etal., 2015;
Colliver etal., 2006; DiNitto & Choi, 2011). The NSDUH
data indicated that older persons who currently take can-
nabis were statistically more likely to have started taking
cannabis before the age of 30 years, with many starting
before the age of 18years. These persons who initiated can-
nabis use before the age of 30 years make up half of all
those older than 50years who used it recently, and nearly a
quarter of these consistent users took cannabis at least 3–4
times per week in the past year. Past-year cannabis use also
has been associated with gender (men are more likely to use
than women), marital status (those who are not married are
more likely to use), and race (non-whites are more likely
to use than whites). Persons older than 50years who take
cannabis are more likely to smoke cigarettes, drink alcohol,
and use cocaine and other illicit drugs including opioids.
The majority of all persons older than 50years who
took cannabis in the past year indicated they used less
than once every 10 days, and 25% of all older persons
used less than ve times during the past year (Blazer &
Wu, 2009). More than 9 out of 10 of all older persons
who took cannabis in the past year reported having
no emotional or functional problems, and the majority
indicated they placed no self-limit on their use (Black &
Joseph, 2014). Only 2.0% of persons older than 50years
indicated they have been diagnosed as having abused can-
nabis in their lifetime, and only 0.9% have ever received
professional treatment for taking cannabis, though 20.7%
individuals who used in the past year reported seeking
treatment for alcohol or some other substance besides
cannabis at some point in their life (Blazer & Wu, 2009;
Wu & Blazer, 2011). Although there is reason to be con-
cerned that increasing cannabis use among older persons
may contribute to increased rates of substance misuse or
other undesirable outcomes such as overdoses and trafc
accidents, the overwhelming majority of older adults do
not experience negative outcomes. In fact, an increasing
number of reports have highlighted the benets that older
persons derive when taking cannabis (Ahmed, van den
Elsen, van der Marck, & Rikkert, 2015).
Charting the Pathways Between Cannabis
and Older Persons
One way to illuminate the growing intersection between
cannabis use and United States’ aging population is to
deploy a paradigm in which individual outcomes (e.g., tak-
ing cannabis) are assumed to be shaped by cohort effects
(e.g., more favorable attitudes held by one generation
but not another) as well as period effects (e.g., historical
events such as cannabis legalization) and age effects that
Figure1. Past-year cannabis use by age group.
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occur over the life course (e.g., health problems). O’Malley,
Bachman, and Johnston (1988) originally applied this per-
spective to examine the dynamic changes in cannabis use
among nationally representative panels of high school sen-
iors who graduated between 1976 and 1986 (Figure2).
In trying to understand why cannabis use increased
and then decreased among succeeding graduating classes,
they referred to a period effect. In particular, O’Malley
and his colleagues attributed the decreasing cannabis use
among seniors graduating after 1981 to national efforts
to curtail illegal drug use initiated by the Reagan admin-
istration. O’Malley and his colleagues then linked the con-
sistent decreases in cannabis use after the age of 21years
to maturation (age effect) and argued that taking canna-
bis declines as individuals assume more professional and
personal responsibilities. Other researchers (e.g., Miech &
Koester, 2012) have since deployed the age–period–cohort
paradigm to examine contemporary patterns of cannabis
use among nationally representative panels, but little effort
has been made to analyze the pathways associated with
varied cannabis use among older persons.
According to social learning theory, individual attitudes are
developed through social interactions and are maintained
through conditioning, imitation, and reinforcement (Black &
Joseph, 2014). Persons born between 1946 and 1964 have
consistently held more favorable attitudes toward legalizing
cannabis than persons born prior to 1945 (e.g., the silent
generation born between 1925 and 1945). By the time these
“baby boomers” graduated from high school, 43% held the
opinion that marijuana should be legalized (Black & Joseph,
2014). Although such favorable attitudes toward legaliza-
tion dropped to 17% in 1990 (reecting the period effect
associated with the Reagan administration, as identied by
O’Malley etal.), the boomers’ positive attitudes toward can-
nabis have been increasing steadily ever since. By 2000, as the
leading edge of the baby boom cohort reached and surpassed
their 50th birthdays, 34% were in favor of legalizing canna-
bis (Black & Joseph, 2014). Other researchers have found
that as general public opinion about cannabis has become
less negative, older individuals have become more likely to
adopt favorable attitudes (Schuermeyer etal., 2014).
Changing attitudes among older adults also have been
tied to perceptions about the medical benets of cannabis.
Kalata (2004) reported that nearly 60% of persons over the
age of 45years believed cannabis provided a medical bene-
t and 72% believed doctors should be allowed to recom-
mend medical cannabis. Although such attitudes were higher
among those who previously had taken cannabis, nearly two
out of every three who never took cannabis at any point dur-
ing their life also held such favorable attitudes about medical
benets. Wang and Chen (2006) suggested that such attitude
changes can occur when a person assigns a higher degree of
relevance to an issue. In this case, when facing a health crisis,
an older adult may be more likely to engage in processing
new information that ultimately may alter a long-standing
attitude about how to treat the health problem. For example,
suppose some older person who historically has held nega-
tive attitudes toward cannabis begins to suffer with intract-
able pain. As the pain progresses and remains inadequately
treated, the older adult may receive information about the
potential benets of taking cannabis from a patient advo-
cacy organization such as the ALS (Amyotrophic Lateral
Sclerosis) Foundation. The older patient may then inquire
of his or her physician if cannabis may provide some sort of
benet. This sort of information processing reects how a
long-held attitude about cannabis can be altered.
In 2014, favorable attitudes among aging baby boomers
reached 52%, and Black and Joseph linked these increas-
ingly more favorable views with increasing rates of past-
year use among those older than 50 years. In 2000, the
percentage of older persons who had tried marijuana at
least once in their lifetime reached 23% among 50–64year
olds and 3% among those aged 65 and older. By 2011, life-
time usage rates increased to 44% among those between 50
and 64years old and 17% for persons older than 65years
(Black & Joseph, 2014).
Another perspective suggests the decision to take canna-
bis is based on subjective calculations concerning reward
and risk (Black & Joseph, 2014). Individuals living in states
with medical marijuana laws (MMLs) may perceive less risk
in taking cannabis and, thus, increase their use. Although
most studies linking past-year use rates with states that have
taken some step toward legalizing cannabis have focused
on younger populations, we did nd a few that offered
some insight into whether the introduction of MMLs
had an effect on older persons. Using data from the 2004
National Epidemiologic Survey of Alcohol and Related
Figure2. Pathways to cannabis use among older adults.
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conditions as well as the 2004 NSDUH, Cerdá, Wall, Keyes,
Galea, and Hasin (2012) identied signicant statistical dif-
ferences in past-year use rates between those living in states
with and without MMLs, and these persisted across all age
groups. Amore recent study by Wen, Hockenberry, and
Cummings (2015) pooled NSDUH survey data from 2004
through 2012 and contrasted past month cannabis use
rates within those states that adopted MMLs during this
period with those that did not. They found that, among all
persons older than 21years, the introduction of an MML
corresponded with signicant increases in past-month can-
nabis use. Given the lack of signicant differences between
younger and older adults, we surmised that persons older
than 50years living in MML states were just as likely as
younger persons to have increased their past-year use.
Because the NSDUH survey only asks about the ille-
gal use of cannabis, we retrieved registry data from eight
state programs to determine whether older adults were
using legalized medical cannabis as well. In analyzing the
multiyear population summary data presented by four of
these states, we found the total number of older program
participants has been increasing steadily in the last 5years,
and persons older than 60years are representing a greater
portion of the state program population. In Montana, 680
persons older than 60years registered for the state medi-
cal cannabis program in 2010, representing 7.9% of all
program participants; by 2015, the number of older par-
ticipants grew to 2,037 and persons older than 60 years
represented 19.3% of all program participants. In Arizona,
the number of state program participants over the age of
60years totaled 7,191 in 2013 and represented 16.7% of
the registry; by the end of 2015, the number reached 14,680
and persons older than 60years constituted 18.9% of reg-
istered participants. The Colorado registry data revealed
that participants older than 60 years totaled 17,495 in
2014 and increased to 17,877 in 2015. The other state
program registries only recently began collecting patient
data and the proportion of older users ranged from 9.9
to 20.5% of all participants. States in which cannabis has
been approved for recreational purposes do not compile
such data (Figure3).
We suspect the total number and proportion of older
users might be even greater in those states in which efforts
to implement medical cannabis programs are more exten-
sive. In particular, although the majority of states have
moved to legalize cannabis in the past decade, the scope
of these state laws and related implementation efforts vary
considerably (Pacula, Hunt, & Boustead, 2014). Some
states allow recreational use as well as medicinal use for
a wide range of conditions, other state laws and dispens-
ary operations are more restrictive. Pacula, Powell, Heaton,
and Sevigny (2015) found that MMLs vary across no fewer
than four substantive dimensions, and increased use of can-
nabis has been associated with factors such as whether the
state allows for individual cultivation.
As persons become older, they may experience stressful
events such as the loss of a spouse or a lack of sufcient
retirement income, and these age-related events may lead
them to take cannabis as a coping mechanism (Black &
Joseph, 2014). As persons age, the chances of acquiring a
disease or disability that are possibly amenable to medical
cannabis also increase considerably. For example, glaucoma
refers to a constellation of age-related ocular conditions
that constitute the primary cause of blindness among per-
sons older than 65years. Several researchers have reported
that medical cannabis successfully reduces glaucoma-
related ocular pressure and can help prevent blindness, and
the use of medical cannabis for glaucoma is supported by
the American College of Physicians (2008). Another set
of age-related conditions considered amenable to medical
cannabis include cachexia (or wasting syndrome), nausea,
and other diagnosable conditions associated with can-
cer. The National Cancer Institute (2016) indicated that
medical cannabis can successfully stimulate appetites and
be helpful for patients who experience nausea and pain.
Neurologic diseases also are considered amenable to med-
ical cannabis; the American Academy of Neurology (Patel
etal., 2014) supports the use of oral cannabis to improve
symptoms among persons with multiple sclerosis.
We determined that up to 21 states have approved the
use of medical cannabis for such age-related diagnosable
conditions (Marijuana Policy Project, 2016). In reviewing
registry data for patients older than 65years in Colorado,
glaucoma was the primary condition assigned to 3.6%
of older program registrants. (Note: Colorado is the only
state that offered data by age and condition.) We found
cachexia was diagnosed among 1.6% of the registrants,
5.7% had nausea, and 10.8% were identied as having
cancer. The age-related neurologic conditions that are cov-
ered by state programs include amyotrophic lateral scle-
rosis (covered in nine states), muscular dystrophy (two
states), and Parkinson’s disease (three states), and 15.9%
of those older than 65years in Colorado were diagnosed
with one of these. Eight states have extended coverage to
Figure3. State programs by approved conditions.
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persons with Alzheimer’s disease (N= 8), and three states
have approved cannabis for persons receiving palliation or
hospice. In Montana, 14 people obtained medical cannabis
to help navigate the end of life in2015.
Still, by far, the primary application of medical cannabis
has been to alleviate pain, generally dened as central and
peripheral neuropathic pain or more specically as nocicep-
tive pain associated with a particular condition (Erickson &
Kiser, 2016). We determined 19 states have approved the
provision of medical cannabis for persons diagnosed with
symptoms of pain and, in reviewing the patient registry
data, 89.7% of those older than 65years in the Colorado
program had listed pain as a primary or secondary con-
dition. In an independent study of persons who enrolled
in a Michigan medical cannabis program, Illgen and his
colleagues found that 87% of new program participants
were looking to relieve symptoms of pain. They also found
that 27% of these newly enrolled patients were older than
50years, and 79% of these older participants never used
cannabis before (Ilgen etal., 2013).
In linking the state registry data with the number of
approved conditions, it was apparent that states with higher
participation rates among older adults had approved the
use of cannabis for a greater number of age-related condi-
tions including neuropathic pain. As more states look to
legalize medical cannabis and expand the menu of quali-
ed conditions, we suspect the number of older adults who
take cannabis should increase substantially as perceived
medical need appears to be a prominent starting point for
those who take cannabis for the rst time since they were
younger or for the rst time ever (Figure4).
Moreover, the Institute of Medicine (1999) and American
College of Physicians (2008) have endorsed the use of medi-
cal cannabis for a limited number of age-related conditions,
and such endorsements appear to be having an impact on
the perceptions of medical doctors and other health care
providers. In a survey of 1,446 readers of the New England
Journal of Medicine, Adler and Colbert (2013) found that
76% supported the use of medical cannabis in a case study
in which an older woman was diagnosed with metastatic
cancer and suffering with nausea and pain. Although sev-
eral other provider organizations (e.g., American Medical
Association, American Nurses Association, American
Pharmacists Association) have stopped short of endorsing
the use of medical cannabis, they all have called for more
public education and training of their provider constitu-
encies with particular emphasis being placed on differen-
tiating the legal risks associated with a doctor prescribing
cannabis (i.e., a FDA violation) relative to the risks of a
doctor recommending it (i.e., as protected by free speech).
Arguably, as medical doctors and other allied health profes-
sionals become more educated about the potential uses of
medical cannabis and how to communicate this informa-
tion legally, they may be more likely to recommend can-
nabis for some of their older patients. As suggested earlier,
such authoritative cues may alter patient attitudes about
taking medical cannabis, particularly among those who
historically had not supported cannabis legalization or may
continue to disapprove of taking cannabis for recreational
Cannabis, Opioids, and End ofLife
Much of the previous work concerning cannabis use
among older persons has pointed to negative outcomes.
As more older persons take cannabis, the number of those
who abuse or become dependent will increase; as more
older adults abuse or become dependent on cannabis, they
will place a greater demand on specialty service providers
(Blazer & Wu, 2009; Wu & Blazer, 2011). Although these
studies present valid public health concerns that already
have captured the attention of policy makers and pub-
lic ofcials, the use of cannabis among older adults also
should be juxtaposed to the potential benets.
For example, some older adults are taking cannabis
as a viable substitute or complement for addictive and
potentially harmful prescription medications. Lucas and
colleagues (2012) found that among 404 registered par-
ticipants from 4 Canadian compassionate care clubs (i.e.,
authorized cannabis dispensaries), 67.8% took cannabis
as a substitute for prescription medication. In a follow-
up, 80% of another sample of 473 club members reported
substituting cannabis for prescribed pharmaceutical medi-
cations. These substitutions occurred most often among
persons experiencing pain (87%), and the primary reasons
for doing so was to decrease side effects and improve symp-
tom management (Lucas etal., 2015).
Increased access to medical cannabis also has been
linked with a reduction in negative outcomes associated
with opioid use. In contrast to the number of opioid over-
doses within states with and without MMLs, Smart (2015)
found that opioid related deaths increased across all states,
but such deaths were 25% less likely to occur in those
states with MMLs and opioid deaths specically were less
Figure4. State program participation among older adults.
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common among older persons. Given that West, Severtson,
Green, and Dart (2015) reported that the rate of prescrip-
tion opioids is highest among women older than 60years
(8.6% compared with 4.7% for those aged 20–39years),
such ndings highlight a need to consider medical canna-
bis as a possible alternative to prescribing opioids for older
adults—a sentiment expressed publicly at a recent Senate
Special Committee on Aging hearing entitled, “Opioid Use
Among Seniors – Issues and Emerging Trends.”
At the state level, Montana and New Mexico recently
have moved to approve cannabis for dying patients. In
doing so, these states have established a viable alternative
to address the long-standing public health failure to ade-
quately treat pain at the end of life (Imhof & Kaskie, 2008).
Not only have these state policy makers facilitated targeted
access to those who would appear to benet substantially
from taking medical cannabis, they have taken a substan-
tial leap to advance implementation of the federal Patient
Self-Determination Act of 1989. In particular, by adding
end of life to the roster of qualied conditions, these states
have facilitated the opportunity for older adults to partici-
pate in directing their own course of end-of-life care and
have offered a greater number of real choices about dying
as pain-free as possible.
We have used an age–period–cohort paradigm to explicate
divergent pathways of cannabis use among the older adult
population and demonstrate how attitudes, laws, and indi-
vidual health needs can shape these paths. This analysis has
lead us to identify several kinds of research that would be
useful to policy makers. On the one hand, we certainly rec-
ognize a need for more biomedical studies focusing on the
individual health outcomes of taking cannabis for a wide
array of age-related diseases and disorders. We also see a
need for clinical research studies that compare older adults’
use of cannabis with prescription opioids and other phar-
maceutical derivatives such as cannabidiol (Ahmed et al.,
2015). On the other hand, there is a need to expand pub-
lic health research that encompasses the legal, medical, and
behavioral issues surrounding cannabis use and older adults.
How are doctors and other professionals talking to older
patients about medical cannabis? Should states with limited
MMLs extend coverage to more age-related medical con-
ditions such as end of life? Should states extend insurance
coverage for older adults who take cannabis as a substitute
for opioids? At this time, these sorts of critical public health
policy questions cannot be answered largely because there
is a pervasive lack of reliable and representative information
being collected about cannabis and older persons. Astate-
wide or national survey that accounts for how changing
legal, medical, and other norms have affected older adults’
attitudes and behaviors about taking cannabis certainly
would help advance the public policy conversation.
Meanwhile, the United States is about to enter a period
when the older adult population is expected to double
(Ortman et al., 2014), the cannabis economy may grow
vefold (Caulkins et al., 2015), and federal ofcials con-
tinue to wrestle incrementally with a variety of controver-
sial and technical issues such as whether cannabis should be
classied in the same category as heroin (Bostwick, 2012).
Although these certainly are critical issues for federal policy
makers to resolve, it is here we turn our attention to the
critical role of the states.
For more than two decades, cannabis policy across
the United States has reected a model of federalism in
which state governments have become laboratories, as
demonstrated by the increasing number of states that have
advanced medical cannabis programs, the lack of enforce-
ment being exercised by key federal agencies, and the
recent decision by the Supreme Court to refuse to consider
the state of Nebraska’s claim against the state of Colorado
(Sevigny & Pacula, 2014). By not actively enforcing the
supremacy of federal policy concerning the classication
of cannabis as a Schedule 1 narcotic, the states have been
left to experiment with some of the most critical aspects of
program development and implementation such as estab-
lishing eligibility criteria, dening dispensation mecha-
nisms, nancing, and maintaining oversight (Sevigny &
Pacula, 2014). Perhaps these laboratories also will experi-
ment with increasing use of cannabis among older persons
as a way to reduce opioid misuse or the undertreatment of
pain at the end of life.
This research was supported by the Department of Health
Management and Policy, University of Iowa.
The authors thank Brad Wright for reviewing this manuscript.
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