Background: Cannabis use and cannabis use disorder (CUD) have become increasingly prevalent, with a notable rise in the United States due to legalization and greater accessibility. Moreover, there is a growing interest in cannabis use among older adults, who often turn to it form medicinal purposes. However, the association between cannabis use and mental health in older adults remains complex and requires further investigation to better understand if cannabis could have potential therapeutic benefits. Understanding these dynamics is crucial for informing policy and clinical interventions, including formulating guidelines for use and early interventions. The goal of this dissertation is to better understand the relationship between cannabis and mental health in middle-aged and older adults via the following three aims (chapters). Methods: Chapter 1- A scoping review was conducted on the existing literature to synthesize current research on cannabis use and depression or anxiety in middle-aged and older adults. Secondary analyses were conducted in chapters 2 and 3 with data from the National Epidemiological Survey on Alcohol and Related Conditions-III (NESARC-III) to investigate the relationship between cannabis use and mental health in middle-aged and older adults. Chapter 2- A logistic regression analyses was run to examine the association between a diagnosis of mood or anxiety disorder and cannabis use disorder controlling for sex, race/ethnicity, education, physical health, heavy alcohol use, tobacco use, and other drug use. Chapter 3- A zero inflated negative binomial regression model was run including interaction terms for sex, heavy alcohol use, other drug use, and tobacco use. All analyses use an alpha of .05. Results: Our scoping review revealed an unclear association between cannabis use and depression or anxiety in middle-aged and older adults, with a multitude of articles reporting different associations. Findings from our two analytical aims found a positive association between lifetime diagnosis of depression or anxiety and cannabis use disorder, as well as cannabis use frequency. This relationship was also shown to be partially moderated by sex, alcohol use, other drug use, and tobacco use. Conclusions: Our results have potential to inform clinicians and the need to be vigilant in screening older adults for cannabis use and mental health disorders and make attempts to understand the different dynamics of cannabis use.

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Background: Nationally, there is a sharp increase in older adults using opioids and seeking treatment for opioid use disorder (OUD). Increasing knowledge of harm reduction principles and access to harm reduction supplies and services are effective ways to reduce opioid-related harms such as overdose. However, older adults are often overlooked in harm reduction efforts in part due to stigmatizing beliefs that older adults do not use drugs. The increasing prevalence of OUD among older adults presents unique challenges in providing age-appropriate tailored harm reduction services. This dissertation aimed to assess knowledge, utilization, and ownership of harm reduction supplies and services among patients aged 55 and older in opioid treatment programs (OTPs) and explore the acceptability, feasibility, and implementation considerations of integrating tailored harm reduction interventions for this population.Methods: We conducted a sequential mixed methods approach within two OTPs across three studies. Study 1 utilized cross-sectional surveys from 75 OTP patients to assess opioid overdose knowledge, naloxone ownership, and utilization of harm reduction services. Multivariable logistic regression examined correlates of naloxone ownership. Study 2 conducted qualitative interviews with 25 OTP patients to explore acceptability and perceived barriers to accessing harm reduction services. Study 3 interviewed 15 OTP providers to evaluate the acceptability, feasibility, and appropriateness of delivering age-tailored harm reduction services. Results: In Study 1, 65% of participants owned naloxone at the time of study. However, only 9% carried naloxone and 17% had ever received overdose education. Correlates of naloxone ownership in the adjusted model included age in years and familiarity with naloxone distribution programs; opioid overdose knowledge was not significantly associated with naloxone ownership. Study 2 revealed high acceptability of harm reduction services among older adult patients, but identified barriers including intersectional stigma, logistical challenges, and lack of tailored and age-appropriate services. Study 3 found that OTP providers viewed integrating age-tailored harm reduction services as necessary and important but noted significant implementation challenges such as resource limitations, patient complexity, and sustainability. Conclusions: While naloxone ownership was moderate among older adults in OTPs, there were significant gaps in having received overdose education and naloxone carriage. Patients and providers reported high acceptability and perceived need of integrating age-appropriate harm reduction interventions but identified significant multi-level barriers to care. Our findings highlight the critical need for targeted interventions, policy changes, and implementation strategies to increase access and sustainability of age-appropriate and tailored harm reduction services for older adults in OTPs.

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