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We studied the impact of legalization on cannabis-related emergency department visits in states with varying degrees of legalization. Cannabinoid immunoassay results and cannabis-related International Classification of Diseases ninth and tenth versions codes were obtained for emergency department visits over a 3- to 8-year period during various stages of legalization: no state laws, decriminalized, medical approval before dispensaries, medical dispensaries available, recreational approval before dispensaries and recreational dispensaries available. Trends and monthly rates of cannabinoid immunoassay and cannabis-related International Classification of Diseases code positivity were determined during these legalization periods. Results: For most states, there was a significant increase in both cannabinoid immunoassay and International Classification of Diseases code positivity as legalization progressed; however, positivity rates differed. In most states with no laws, there was a significant but smaller increase in cannabinoid immunoassay positivity rates. Conclusions: States may experience an increase in cannabis-related emergency department visits with progression toward marijuana legalization. The differences between states, including those in which no impact was seen, are likely multifactorial and include cultural norms, attitudes of local law enforcement, differing patient populations, legalization in surrounding states, availability of dispensaries, various ordering protocols in the emergency department, and the prevalence of non-regulated cannabis products. Keywords: ICD codes; Marijuana; Tetrahydrocannabinol; cannabis; decriminalization; legalization; recreational use; urine drug screen. Substances Cannabinoids Medical Marijuana.

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