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.Cannabis use also increases the perception of poor health above and beyond cigarette smoking and other relevant factors.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 grow tent 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 cannabis 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 grow lights for cannabis in efforts to address insomnia and sleep disturbances.The current study did not examine variability in sleep patterns and sleep problems that may be particularly salient to MC users.
Meanwhile, treatments such as cognitive– behavioral therapy for insomnia should be routinely available to veterans who may derive greater benefit from this behavioral strategy than resorting to using cannabis with its known adverse effects on health, cognitive, and psychological functioning.Finally, VHA providers should expect an increase in the number of veterans seeking voluntary treatment for CUD, because more cannabis users now seek treatment since the legalization of MC use.Therefore, routine screening or assessment for cannabis use and CUD in the VHA is recommended, particularly in the context of assessing for sleep problems and trauma related symptoms.At a minimum, researchers and clinicians should not be combining cannabis use with other illicit drugs of abuse in terms of screening and treatment recommendations.Several study limitations warrant mention.As with many veteran samples, a small number of female veterans limited the generalizability of our findings to female veterans who are using the VHA for health care services.The caveat to our and other similar cross-sectional findings is that these data cannot establish precedence of cannabis versus other substances or whether MC use leads to subsequent reductions in alcohol or other illicit or prescribed substances, or whether sleep problems amount to increased MC use or vice versa.Planned longitudinal analyses of the larger parent study will indeed help clarify the putative relationship between these variables and MC use in this veteran sample.Next, characterizing MC and RC groups as mutually exclusive categories does not take into account the nuance and complexity of using cannabis for reasons that can be viewed as both medicinal and recreational.Future studies might need to utilize a continuous index of the proportion of use for medicinal and recreational purposes and account for differences across states and jurisdictions in their definitions of medical use of cannabis.Next, it is possible that responding to the questionnaires specific to medicinal cannabis use could have influenced responses on the subsequent MPS assessing cannabis-related problems for the MC users.Finally, the study was explicitly focused on examining differences between MC and RC users in terms of the presence of PTSD and MDD diagnoses, the two psychiatric disorders that are most prevalent among the returning veterans.However, comorbidity with other anxiety disorders may be important to investigate in future comparisons between MC and RC users.In conclusion, our findings suggest research on MC use in veterans needs to continue.In addition, although the line between cannabis use for medicinal and recreational reasons may often be blurred,current findings help identify motivations underlying medicinal cannabis use among veterans.Future research can further resolve and address specific needs of veterans seeking medicinal cannabis, which could inform mental health treatment within the VHA.Legalization of cannabis production in 2017 has generated demands for state regulatory, research and extension agencies, including UC, to address the ecological, social and agricultural aspects of this crop, which has an estimated retail value of over $10 billion.Despite its enormous value and importance to California’s agricultural economy, remarkably little is known about how the crop is cultivated.While general information exists on cannabis cultivation, such as plant density, growing conditions, and nutrient, pest and disease management , only a few studies have attempted to measure or characterize some more specific aspects of cannabis production, such as yield per plant and regional changes in total production area.