With the majority of U.S.states having adopted legislation to medically and/or recreationally legalize cannabis, the already high prevalence of cannabis use is expected to further increase nationwide, especially among existing users.States that allow the legal use of cannabis for medicinal purposes have higher rates of cannabis use and cannabis use disorder in national survey data and specifically within the Veterans Health Administration.Veteran advocacy groups have been created to further veterans’ rights to access cannabis for medical purposes and discuss its use with their VHA providers.There are also published reports that veterans perceive cannabis to be a low-risk or safe substance unlike other drugs of abuse and expect cannabis to provide relief from symptoms of combat-related trauma.However, there has been little research on the patterns and correlates of MC use specifically among veterans.Growing research indicates that rates of cannabis use and CUD are particularly elevated among veterans with post traumatic stress disorder and major depressive disorder.These individuals are particularly likely to use cannabis as a means of coping with negative affect and with sleep disturbances.Nonveter an research also identifies cannabis use as an emotion-regulatory strategy to reduce or manage perceived aversive psychological and mood states.However, although such sleep and emotion regulation motives are commonly endorsed reasons for non-MC use among veterans in general, little is known about potential differences in motives among veterans using MC relative to those using cannabis recreationally for non-medical reasons.Motivation for MC use has been examined in non-veteran populations , with the most commonly endorsed reasons for use being pain, anxiety, and sleep problems.Besides pain management, relief of anxiety, especially PTSD, appears to be a prevalent motive for MC use in community samples and among veterans.Indeed, PTSD is now recognized as a qualifying condition by the majority of states permitting legal access to medicinal cannabis.
Sleep disturbance,grow cannabis particularly in conjunction with PTSD, is associated with more frequent and more problematic use of cannabis in non-veteran samples and with frequent cannabis use and CUD among veterans.Thus, MC use may be driven by specific motives for use that are inter-related with certain comorbid conditions that are particularly prevalent in veteran populations.Medical dispensary patients also report using cannabis as a substitute for prescription medication and for alcohol , with the most common motives for using cannabis instead of alcohol or illicit or prescription drugs being fewer perceived side effects, better symptom management , and decreased severity of withdrawal with cannabis.Indeed, the vast majority of MC patients self-report at least moderate symptom relief across all conditions.Preliminary prospective research found a 42% reduction in use of prescribed opiates over 3 months following the initiation of MC treatment.Yet, cannabis used specifically for pain management among MC users is significantly associated with past history of more severe substance use patterns including use of alcohol, illicit drugs, and non-prescribed pain relievers.In contrast to the growing literature on MC use, only a few non-veteran studies explicitly compared MC and RC users on cannabis-related behaviors and motives.MC users were found to have poorer health but lower levels of alcohol and drug use disorders relative to RC users.Compared with RC users, MC users have reported lower frequency of alcohol and drug problems during a visit to the emergency department and primary care clinic.Among MC users, patients with state legal access to cannabis had lower rates of other substance use relative to cannabis users without access to MC who might have used cannabis recreationally.To date, there has been little research on MC use in veteran populations, with only one study differentiating between MC and RC use in veterans.Findings from this online survey of veterans recruited from a pro-marijuana legalization listserv showed that MC users had more PTSD symptoms and greater combat exposure than RC veterans as well as lower levels of alcohol use.Veteran research can greatly inform federal and state cannabis-related policies, which are in constant flux yet shifting toward more tolerant practices regarding MC use within the VHA.These policies are especially relevant to returning veterans from the Operation Enduring Freedom/ Operation Iraqi Freedom/Operation New Dawn conflicts, because they have endured high stress levels due to their military experiences and post deployment reintegration problems.Like non-veteran MC users, OEF/OIF/ OND soldiers, particularly those with PTSD, also report poor general health and increased somatic symptoms such as chronic pain , greater medical services utilization , and worse sleep.
Anecdotal reports indicate returning veterans also use cannabis as a substitute for other prescribed and non-prescribed substances and may perceive cannabis to be less harmful than opioids.Therefore, both actual and perceived poor health combined with increasingly favorable attitudes toward cannabis among veterans may further increase the likelihood of OIF/OEF/OND veterans seeking MC.In summary, use of MC within the VHA is a growing clinical issue.However, there is a dearth of studies differentiating MC versus RC use patterns and correlates in veterans, despite their disproportionately higher rates of PTSD, anxiety, sleep, and chronic pain diagnoses relative to the general population.The present study has two aims.First, we describe the characteristics and motives for past year MC use in a sample of returning veterans.Second, we compare past-year MC versus RC users on socio-demographic factors and diagnostic characteristics, substance use, motives for cannabis use, and physical and mental health variables.MC use was determined by veteran self-report of using cannabis for medicinal purposes, regardless of whether a veteran possessed a medical marijuana registration card.Frequency of marijuana use was covaried in these analyses because MC users typically endorse daily or almost daily patterns of use.We hypothesized that MC veteran users would endorse more salient coping and sleep cannabis use motives relative to RC users as a means of coping with psychiatric and medical conditions.These comparisons between MC and RC users can inform the development of future VHA policy as well as current screening, assessment and clinical practices with OIF/OEF/OND veterans.To our knowledge, this is the first study to compare MC and RC users in a sample of veterans enrolled in a VHA facility.Results indicated that the most frequently endorsed conditions for MC use were anxiety, stress, PTSD,pain, depression, and insomnia.Consistent with findings from non-veteran studies, this veteran study demonstrated that MC users endorsed worse physical and mental health functioning relative to RC users.MC users were three times more likely to meet criteria for PTSD than RC users, adjusting for frequency of cannabis use, which varied across the two groups.As hypothesized, the greatest difference between MC and RC users was found for sleep as the reason for cannabis use.Furthermore, this difference remained and was one of the two significantly different motives when adjusting for frequency of use.Mental health concerns were highly prevalent in this veteran sample, in contrast to previous findings identifying pain as the most prevalent qualifying condition among non-veteran MC users.Specifically, more MC users endorsed anxiety and PTSD than chronic pain and other psychological conditions.As mentioned previously, sleep emerged as one of the most important motives for MC use, along with using for relaxation reasons and to relieve PTSD.This is consistent with other studies , indicating that sleep motives are the most robust significant mediating factor underlying the relations between both PTSD with cannabis use and increased risk of CUD.
Furthermore, MC users were more likely to meet criteria for current and lifetime diagnosis of PTSD than were RC users.One prior online survey of veterans similarly demonstrated that, relative to RC users, MC users endorsed more PTSD symptoms on a PTSD screening checklist and reported greater combat exposure and greater subjective arousal to items on the PTSD screen.These findings are not surprising given the high prevalence of PTSD among veterans using indoor cannabis grow system and with increasing number of MC users endorsing PTSD symptoms and/or history of trauma.Although controlled evidence on effectiveness of MC as PTSD treatment is currently lacking, preliminary research indicates cannabinoid receptor agonists to have beneficial effects in terms of relief from PTSD symptoms.Clearly, data from clinical trials is needed to help clarify whether cannabis helps relieve PTSD symptoms or whether it iatrogenically maintains some aspects of PTSD.Evidence in support of the endocannabinoid system’s therapeutic potential in the modulation of stress response may help stimulate the sorely lacking empirical research on the use of cannabis for psychological distress and sleep problems.Additional findings regarding MC users are worth noting, especially in the context of acquiring and using cannabis.For example, although 62% of MC users reported having a medical condition that would qualify them for a medical marijuana registration card in their state, only 24% reported having obtained one.One possible explanation for this discrepancy that we can posit from our data is that nearly 26% of MC users reported that they refrained from discussing medical cannabis with their doctor out of concern that doing so may get them into trouble and/or negatively affect their benefits and services at the U.S.Department of Veterans Affairs.Veterans also indicated they can more easily access cannabis from a source that does not require a state-issued medical card or that they obtained cannabis from someone else who had a medical marijuana card.Factors contributing to this may include prohibitive costs of maintaining a medical marijuana registration or higher prices of cannabis sold legally in dispensaries than on the black market.Future qualitative research might help explicate the nature of this incongruity.As increasing numbers of mental health care providers encounter veterans who use cannabis, many may be concerned about the risk of misuse of cannabis and other substances.
Consistent with national sample data , our findings suggest that while cannabis-related problems and CUD were more prevalent among MC users relative to RC users, none of these differences remained significant in analyses controlling for cannabis use frequency.With respect to other substance use, MC users reported lower frequency of alcohol use, as compared with RC users.This finding is consistent with other studies reporting lower alcohol problem severity and lower frequency of drug use in MC users relative to non-medical cannabis users.Groups differed specifically in terms of the frequency of alcohol consumption but were similar in terms of quantity of alcohol used once frequency of cannabis use was controlled in the analyses.Furthermore, alcohol was the only significant cannabis-use motive more frequently endorsed by RC relative to MC users in the analyses adjusted for frequency of cannabis use.Consistent with the finding on higher frequency of alcohol use, alcohol-intoxication motives reflect greater prevalence of problem alcohol use among RC as compared with MC users.Of note, while MC users reported using cannabis at least half of the time or more as a substitute for prescription medication, they did not use it as a substitute for alcohol or other drugs as often.These findings are consistent with other studies indicating significant history of past alcohol, drug and prescription substance use and misuse among MC users , with evidence from other studies suggesting cannabis is often effectively used as a harm reduction strategy to substitute for alcohol, opiates, and other drugs.For example, among Canadian medical cannabis dispensary patients, over 36% were found to report using cannabis as a substitute for illicit drugs, 41% reported using cannabis as a substitute for alcohol, and nearly 68% reported using cannabis as a substitute for prescription drugs.The most commonly endorsed reasons for substituting cannabis for the previous substances included the belief that cannabis led to less withdrawal, produced fewer side effects, and provided better symptom management.Recommendations for substance use disorder treatment providers of veterans using MC in VHA and seeking SUD treatment are limited because of the dearth of clinical trials on the impact of MC use on the effectiveness of addiction treatment combined with equivocal findings on the effect of cannabis on alcohol and drug treatment.specifically, some studies do not find negative impact of cannabis on treatment retention or compliance with opiate maintenance therapy or smoking cessation , yet cannabis has been implicated in worse outcomes in opiate and alcohol treatments.Future longitudinal studies and controlled research specifically examining the role of MC use on treatment of other SUDs is needed to help elucidate its impact on addiction treatment.Another implication of these findings is the need for more innovative treatment solutions for veterans with PTSD and sleep disturbance who may be turning to cannabis in search of relief of their symptoms.Many of the individuals with PTSD and CUD comorbidity do not have access to evidence-based integrated trauma-focused and CUD treatment.Furthermore, although MC users cited improving sleep as a central reason to use cannabis, both MC and RC users had endorsed clinically significant poor sleep quality, as measured by the PSQI, despite their use of cannabis in efforts to address insomnia and sleep disturbances.