Supplementary Material for: Cannabis Certifications for Severe Chronic and Intractable Pain: Geographic Patterns Across Pennsylvania, USA

Introduction: Chronic pain is the most common qualifying condition found in states with legal (certified) access to medical cannabis (MC). We assessed the geographic distribution of MC certifications for severe chronic or intractable pain in Pennsylvania (PA) between 2018 to 2024, identifying relationships between community variables with the percentage of adults with a MC certification for pain.

Methods: Using data from the PA Department of Health (PDOH) from 2018 to 2024 (N = 44,645 to 165,740 certifications for pain / year), we mapped Zip codes associated with MC certifications for pain to counties and Zip code tabulation areas (ZCTAs), geographic areas that approximate a standardized representation of zip codes for statistical purposes. The difference between the highest and lowest counties was determined. A linear regression evaluated correlations between community variables and the percentage of adults in geographical areas with a MC certification for pain in 2024.

Results: There was almost a four-fold difference in the percent of adults with a MC certification for pain in the highest (Perry = 2.3%) versus lowest (Tioga = 0.6%) counties in 2024. Bradford and Tioga County had a significantly (p < 0.05) lower percentage certified relative to the county-wide average. There was a significantly higher proportion of certifications for pain in counties with larger population densities of adults (1.76 +/- 0.12%) than counties with smaller population densities (1.38% +/- 0.14%) of adults (t(65) = 4.66, p < 0.001, d = 1.14). At the county level, higher median household income (r(65) = +0.335, p < 0.01), lower median age (r(65) = -0.241, p = 0.0499), and higher Rural-Urban Continuum Code (r(65) = +0.644, p < 0.001) were associated with a greater percentage of adults with an MC certification for pain using simple linear regression. Using a multiple regression model, only Rural-Urban Continuum Code was significantly associated with the percent of adults with an MC certification for pain (p < 0.001). At the ZCTA level, the proportion of non-White individuals, including Hispanics, showed a significant inverse association with the percent of adults with an MC certification for pain (r(1,722) = -0.07, p < 0.01).

Conclusions: This study identified four-fold county level disparities in MC certifications for pain. The association between median household income and MC pain certifications may indicate differences in accessibility of MC based on financial status. Further research may be warranted pending any changes to the legal status or demand for MC.

引言：慢性疼痛是合法获得认证的医用大麻（medical cannabis, MC）准入州中最常见的合格准入病症。本研究针对2018至2024年宾夕法尼亚州（Pennsylvania, PA）内针对重度慢性或难治性疼痛的医用大麻认证的地理分布展开评估，分析社区变量与持有疼痛相关医用大麻认证的成年人占比之间的关联。

方法：本研究使用宾夕法尼亚州卫生部（Pennsylvania Department of Health, PDOH）2018至2024年的相关数据（每年疼痛相关认证数量为44645至165740例），将疼痛相关医用大麻认证关联的邮政编码（Zip code）映射至县（county）与邮政编码统计区域（Zip Code Tabulation Area, ZCTA）——后者是为统计目的对邮政编码进行标准化近似的地理区域，并确定了各县间最高与最低认证占比的差值。本研究采用线性回归分析2024年各地理区域中持有疼痛相关医用大麻认证的成年人占比与社区变量之间的相关性。

结果：2024年，疼痛相关医用大麻认证成年人占比最高的佩里县（2.3%）与最低的蒂奥加县（0.6%）之间相差近4倍。布拉德福德县与蒂奥加县的认证占比显著低于全县平均水平（p<0.05）。成人人口密度较高的县的疼痛相关认证占比（1.76±0.12%）显著高于成人人口密度较低的县（1.38%±0.14%，t(65)=4.66，p<0.001，d=1.14）。县级层面，通过简单线性回归分析显示，家庭收入中位数更高（r(65)=+0.335，p<0.01）、年龄中位数更低（r(65)=-0.241，p=0.0499）以及城乡连续统代码（Rural-Urban Continuum Code）更高的县，其持有疼痛相关医用大麻认证的成年人占比更高。采用多元回归模型时，仅城乡连续统代码与疼痛相关医用大麻认证成年人占比显著相关（p<0.001）。在邮政编码统计区域层面，包括西班牙裔在内的非白人个体占比与疼痛相关医用大麻认证成年人占比呈显著负相关（r(1722)=-0.07，p<0.01）。

结论：本研究揭示了县级层面疼痛相关医用大麻认证存在近4倍的差异。家庭收入中位数与疼痛相关医用大麻认证之间的关联，或提示医用大麻的可及性存在基于经济状况的差异。若医用大麻的法律地位或市场需求发生变化，则需开展进一步研究。