2021 Treatment Data Show Higher Cannabis-Related Admission Rates in Many States Without Adult-Use Sales
States without adult-use cannabis sales recorded many of the highest per-capita rates of treatment admissions listing marijuana or hashish as the primary substance in 2021. But the federal data do not show that prohibition caused those higher rates—or that legalization reduces cannabis-related problems.
The findings come from the Substance Abuse and Mental Health Services Administration’s 2021 Treatment Episode Data Set report. TEDS records admissions to treatment facilities that report information to state agencies, primarily facilities that are licensed, certified, or publicly funded.
The report covers 1,482,543 admissions involving people ages 12 and older. Marijuana or hashish was listed as the primary substance in 129,343 admissions. That placed it behind alcohol, heroin, and methamphetamine among the report’s leading primary substances. Depending on the table and denominator used, marijuana represented 8.7 percent of all recorded admissions and 10.2 percent in the report’s standardized primary-substance comparison.
Measured per 100,000 residents, the states with the highest reported rates were:
- South Dakota: 151
- Iowa: 144
- Connecticut: 141
- South Carolina: 119
- Minnesota: 110
- New York: 95
- Wyoming: 85
- Georgia: 84
- North Dakota: 81
- New Jersey: 80
Most of those states did not permit adult-use cannabis sales at the beginning of 2021. Connecticut, New Jersey, and New York enacted adult-use legalization during the year, although retail sales did not begin immediately. South Dakota and Wyoming did not allow recreational sales, while several of the other states had limited medical-cannabis programs.
At the other end of the distribution were states and jurisdictions including New Hampshire, New Mexico, West Virginia, Montana, Puerto Rico, Hawaii, Arizona, Illinois, Maine, Massachusetts, and Pennsylvania. Washington and Oregon, both of which had legal adult-use markets in 2021, did not report usable figures for this portion of the TEDS dataset.
Those comparisons should be treated cautiously. As SAMHSA notes in its TEDS documentation, an admission is not the same as a person: one individual can appear more than once in a year. States also differ in how they define and report admissions, which facilities participate, how treatment is financed, and how people are referred to care. SAMHSA specifically warns that absolute admission counts are not valid for straightforward state-to-state comparisons.
Referral practices may be especially important for cannabis-related treatment. Criminal-justice agencies have historically been a major source of cannabis treatment referrals, including court-ordered referrals that may involve people with varying levels of clinical need. When arrests and court referrals decline after legalization, treatment admissions can fall even if the prevalence of cannabis use disorder does not.
A 2023 study using TEDS data found that the share of young-adult cannabis-treatment admissions originating from the criminal-justice system declined more rapidly after recreational legalization. The authors attributed the change largely to falling cannabis-related arrests and recommended expanding noncriminal referral pathways, including screening and referrals through primary care. The study found a different pattern for adolescents, underscoring that results can vary by age group and by the type of admission being measured. The study is available through PubMed.
Total treatment admissions declined between 2020 and 2021, a period heavily affected by the COVID-19 pandemic. Marijuana-primary admissions also fell from the previous year. That decrease, however, cannot by itself establish a relationship with cannabis legalization because treatment access, reporting, referral patterns, and pandemic disruptions all changed during the same period.
The 2021 TEDS report therefore provides a useful snapshot of where cannabis-primary treatment admissions were recorded, not a test of whether prohibition or legalization produces better public-health outcomes. The most defensible conclusion is narrower: many states without adult-use sales had high reported admission rates, while the reasons for those differences require analysis of treatment capacity, enforcement, referral sources, cannabis-use patterns, and unmet treatment need.
