Narrative review of the safety and efficacy of marijuana for the treatment of commonly state-approved medical and psychiatric disorders

The present investigation aimed to provide an objective narrative review of the existing literature pertaining to the benefits and harms of marijuana use for the treatment of the most common medical and psychological conditions for which it has been allowed at the state level. Common medical conditions for which marijuana is allowed (i.e., those conditions shared by at least 80 percent of medical marijuana states) were identified as: Alzheimer’s disease, amyotrophic lateral sclerosis, cachexia/wasting syndrome, cancer, Crohn’s disease, epilepsy and seizures, glaucoma, hepatitis C virus, human immunodeficiency virus/acquired immunodeficiency syndrome, multiple sclerosis and muscle spasticity, severe and chronic pain, and severe nausea. Post-traumatic stress disorder was also included in the review, as it is the sole psychological disorder for which medical marijuana has been allowed. Studies for this narrative review were included based on a literature search in PsycINFO, MEDLINE, and Google Scholar. Findings indicate that, for the majority of these conditions, there is insufficient evidence to support the recommendation of medical marijuana at this time. A significant amount of rigorous research is needed to definitively ascertain the potential implications of marijuana for these conditions. It is important for such work to not only examine the effects of smoked marijuana preparations, but also to compare its safety, tolerability, and efficacy in relation to existing pharmacological treatments.

Difficulties in emotion regulation are associated with panic symptom severity following a quit attempt among cannabis dependent veterans

BACKGROUND AND OBJECTIVES

Prior research suggests that difficulties in emotion regulation are associated with elevations in panic symptoms. The present study aimed to extend this work by prospectively examining the relation between difficulties in emotion regulation and panic symptoms over the course of a self-guided cannabis cessation attempt.

DESIGN AND METHOD

One hundred and four cannabis-dependent military veterans participated in the study. Difficulties in emotion regulation and panic symptoms were assessed at baseline and at each week during a four-week cessation attempt for a total of five time-points.

RESULTS

Fewer difficulties in emotion regulation were associated with a greater reduction in panic symptoms during the self-guided cannabis cessation period. RESULTS remained significant after statistically adjusting for mean substance use (i.e., cannabis, alcohol, and tobacco) during the study period.

CONCLUSIONS

RESULTS are discussed in terms of integrating adaptive emotion regulation skills training into existing evidence-based treatments for cannabis dependence.

Interactions between disordered sleep, post-traumatic stress disorder, and substance use disorders

Disordered sleep is associated with a number of adverse health consequences and is an integral component of many psychiatric disorders. Rates of substance use disorders (SUDs) are markedly higher among individuals with post-traumatic stress disorder (PTSD), and this relationship may be partly mediated by disturbed sleep. Sleep disturbances (e.g. insomnia, daytime sleepiness, vivid nightmares) are hallmark features of PTSD and there is evidence that individuals with PTSD engage in substance use as a means of coping with these symptoms. However, prolonged substance use can lead to more severe sleep disturbances due to the development of tolerance and withdrawal. Behavioural or pharmacological treatment of disordered sleep is associated with improved daytime symptoms and psychosocial functioning among individuals who have developed PTSD. Initial research also suggests that improving sleep could be similarly beneficial in reducing coping oriented substance use and preventing relapse among those seeking treatment for SUDs. Together, these findings suggest that ameliorating sleep disturbance among at-risk individuals would be a viable target for the prevention and treatment of PTSD and associated SUDs, but prospective research is needed to examine this hypothesis. Enhanced understanding of the interrelation between sleep, PTSD, and SUDs may yield novel prevention and intervention approaches for these costly, prevalent and frequently co-occurring disorders.

Physical activity and cannabis cessation

BACKGROUND AND OBJECTIVES

Based on recent empirical and theoretical work suggesting that physical activity (PA) activates many of the same physiological systems as cannabis, the present study sought to investigate the impact of PA level (ie, low [including none] vs. moderate/high) on a cannabis cessation attempt during the first 7 days post-quit.

METHODS

The present study was a 2 time-point prospective study of 84 cannabis dependent military veterans (3 female) who responded to study flyers, within a Veterans Affairs Medical Center, seeking individuals interested in engaging in a self-guided cessation attempt. All study measures were self-report.

RESULTS

Though no baseline differences between those with low and those with moderate/high levels of physical activity were observed, results revealed that participants who reported low levels of physical activity, versus moderate/high levels, were significantly more likely to report a cannabis lapse during the week following a quit attempt, particularly within the first 4 days of the cessation period. Further, individuals with low levels of PA were also more likely to report greater mean cannabis use during the first 4 days of the cessation period.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Findings suggest that early interventions aimed at increasing physical activity may be useful among individuals with cannabis dependence who are engaged in a cessation attempt.

The comorbidity of sleep apnea and mood, anxiety, and substance use disorders among obese military veterans within the Veterans Health Administration

OBJECTIVES

To determine the relations between obstructive sleep apnea (OSA) diagnosis, the likelihood of being diagnosed with a psychological condition, among obese veterans, after accounting for severity of obesity and the correlated nature of patients within facility. We hypothesized that (1) individuals with a diagnosis of OSA would be more likely to receive a diagnosis of a (a) mood disorder and (b) anxiety disorder, but not (c) substance use disorder.

DESIGN

Cross-sectional retrospective database review of outpatient medical records between October 2009 and September 2010, conducted across all 140 Veterans Health Administration (VHA) facilities.

SETTING

The entire VA Health Care System.

PATIENTS OR PARTICIPANTS

Population-based sample of veterans with obesity (N = 2,485,658).

MAIN OUTCOME MEASURES

Physician- or psychologist-determined diagnosis of psychological conditions including mood, anxiety, and substance use disorders.

RESULTS

Using generalized linear mixed modeling, after accounting for the correlated nature of patients within facility and the severity of obesity, individuals with a diagnosis of sleep apnea had increased odds of receiving a mood disorder diagnosis (OR = 1.85; CI = 1.71-1.72; p < 0.001), anxiety disorder diagnosis (OR = 1.82; CI = 1.77-1.84; p < 0.001), but not a diagnosis of substance use disorder.

CONCLUSIONS

Among obese veterans within VA, OSA is associated with increased risk for having a mood and anxiety disorder, but not substance use disorder, with the strongest associations observed for posttraumatic stress disorder (PTSD) and major depressive disorder (MDD). In addition, this relation remained after accounting for severity of BMI.

The impact of perceived sleep quality and sleep efficiency/duration on cannabis use during a self-guided quit attempt

Poor sleep quality may play a significant role in observed high rates of sustained cannabis use among veterans attempting to quit. We investigated whether individuals with poorer perceived sleep quality (rather than sleep efficiency/duration), as measured via the Pittsburgh Sleep Quality Index (Buysse, Reynolds, Monk, & Berman, 1989), would have less of a reduction in cannabis use (measured via Timeline FollowBack; Sobell and Sobell, 1992) during the first 6 months following a self-guided quit attempt. We expected these effects to remain significant after adjusting for baseline age, posttraumatic stress symptoms, as well as alcohol, tobacco, and opioid use, and cannabis withdrawal severity over the course of 6 months following the cannabis cessation attempt. Generalized linear mixed modeling using a Poisson distribution was employed to test the hypotheses among 102 cannabis dependent, primarily male, military veterans. Results indicated that veterans with poor perceived sleep quality had less of a reduction in mean cannabis use following a self-guided cannabis cessation attempt compared to those with good perceived sleep quality, while efficiency/duration was unrelated to cannabis use outcomes. Conclusions from this study should be considered in light of limitations including the use of self-report measures and generalizability to non-veterans and women.

HIV medication adherence and HIV symptom severity: the roles of sleep quality and memory

The purpose of the current study was to examine the extent to which self-reported sleep quality, a clinically malleable factor, is associated with both HIV medication adherence and self-reported HIV symptom severity. In addition, we sought to examine whether sleep quality may explain the association between HIV medication adherence and symptom severity, as well as the role of self-reported memory functioning in terms of the above relations. This study took place from April 2010 to March 2012. Participants were 129 HIV-positive individuals who completed an ART pill count and series of structured clinical interviews and self-report questionnaires on sleep, memory, and HIV symptom severity. A series of regressions were conducted to test study hypotheses. After accounting for covariates (i.e., problematic alcohol, nicotine, and cannabis use, and mood disorder diagnosis), results indicated that self-reported sleep quality was associated with HIV medication adherence and self-reported HIV symptom severity, and that sleep quality partially mediated the relation between medication adherence and self-reported HIV symptom severity. In addition, memory functioning moderated the relation between self-reported sleep quality and HIV symptom severity, such that the interaction of poor sleep quality and relatively good memory functioning was associated with heightened self-reported HIV symptom severity. This study highlights the importance of assessing sleep and memory among HIV-infected individuals as they may represent treatment targets for those experiencing poor medication adherence or particularly severe HIV symptoms. Such information could lead to the inclusion of adjunct brief interventions to target sleep and memory functioning in order to reduce symptom severity among HIV-positive individuals with poor medication adherence.

The effects of cannabis use expectancies on self-initiated cannabis cessation

AIMS

To prospectively investigate the relation between cannabis use expectancies and cannabis use prior to and during a self-initiated cannabis cessation attempt.

DESIGN

Cohort design that followed participants for 4 weeks following a self-initiated cessation attempt.

SETTING

United States Department of Veterans Affairs medical center.

PARTICIPANTS

One hundred cannabis dependent military veterans.

MEASUREMENTS

The Marijuana Effects Expectancy Questionnaire at baseline; the timeline follow-back procedure at baseline and during the cessation attempt.

FINDINGS

Cannabis use at baseline was associated with positive (P = 0.01), but not negative (P = 0.25), expectancies. Cannabis lapse was associated with positive (P = 0.03) and negative expectancies (P = 0.01), and relapse was associated with positive (P = 0.04), but not negative (P = 0.21), expectancies. The trajectory of average cannabis use during the cessation period was associated with positive (P = 0.03), but not negative (P = 0.96), expectancies. Results were similar in effect and statistical significance when adjusting for demographic factors, motivation to quit cannabis, mental disorder diagnoses, and alcohol and tobacco use, and when analyzing complete data sets obtained through multiple imputation.

CONCLUSIONS

In the USA, cannabis use expectancies, especially those regarding the positive effects of cannabis use, appear to be strongly and consistently linked to cannabis use and quit failure.

Differential associations between perceived and objective measurement of distress tolerance in relation to antiretroviral treatment adherence and response among HIV-positive individuals

The present study sought to extend prior work, showing an association between self-reported distress tolerance and self-reported antiretroviral treatment (ART) adherence, by conducting a multimethod test of the association between distress tolerance and objective measures of ART adherence among a sample of 140 individuals (23.6% female) with human immunodeficiency virus (HIV). Findings indicated that, after accounting for negative affectivity and ART side-effect severity, distress tolerance was significantly associated with pill count adherence as well as viral load. Specifically, a differential association was observed whereby self-reported distress tolerance was associated with pill count adherence, whereas behavioral distress tolerance was associated with viral load. Importantly, no associations were observed between either measure of distress tolerance and CD4 count. Findings are discussed in terms of the importance of both behavioral and perceived distress tolerance assessment among patients with HIV as well as potential clinical implications related to the integration of distress tolerance-focused treatments into existing interventions for individuals with HIV.

Detoxification History and 2-Year Outcomes of Substance Use Disorder Treatment and Mutual-Help Group Participation

Little is known about detoxification (detox) history as a risk factor for poor treatment outcomes among dually diagnosed (substance use and other mental health disorders) patients. We compared patients with a detox history with those who had never received detox on baseline characteristics, subsequent treatment and mutual-help group participation, and substance use and related outcomes at 6-month, 1-year, and 2-year follow-ups. Having a detox history was associated with poorer status at treatment intake, but detoxed patients were functioning as well as never-detoxed patients on alcohol and drug use severity 2 years later. However, having a detox history at baseline was associated with poorer psychological and legal functioning at follow-ups. Assessing detox history in mental health programs would be feasible to implement routinely. Targeting more comprehensive mental health, case management, and 12-step facilitation services to dually diagnosed patients with a history of detox may improve mental health and criminal involvement status.

The impact of exercise on suicide risk: examining pathways through depression, PTSD, and sleep in an inpatient sample of veterans

Suicide has a large public health impact. Although effective interventions exist, the many people at risk for suicide cannot access these interventions. Exercise interventions hold promise in terms of reducing suicide because of their ease of implementation. While exercise reduces depression, and reductions in depressive symptoms are linked to reduced suicidal ideation, no studies have directly linked exercise and suicide risk. The current study examined this association, including potential mediators (i.e., sleep disturbance, posttraumatic stress symptoms, and depression), in a sample of Veterans. SEM analyses revealed that exercise was directly and indirectly associated with suicide risk. Additionally, exercise was associated with fewer depressive symptoms and better sleep patterns, each of which was, in turn, related to lower suicide risk.

The interactive effects of emotional clarity and cognitive reappraisal on problematic cannabis use among medical cannabis users

This study examined whether emotional clarity (i.e., the extent to which one can identify and understand the type and source of emotions one experiences) and cognitive reappraisal (i.e., altering how potentially emotion-eliciting situations are construed to change their emotional impact) would individually or jointly be associated with problematic cannabis use among individuals receiving cannabis for medical reasons (n=153). Findings indicated that problematic cannabis use was predicted by the interaction between emotional clarity and cognitive reappraisal. In particular, low levels of emotional clarity combined with high levels of cognitive reappraisal predicted problematic cannabis use. The current study is the first to demonstrate the interactive effects of emotional clarity and the use of cognitive reappraisal in predicting substance use disorder outcomes. Such findings are important given the lack of empirical data demonstrating for whom and for which conditions cannabis is either beneficial or detrimental.

A comprehensive examination of delay discounting in a clinical sample of Cannabis-dependent military veterans making a self-guided quit attempt

Delay discounting (DD), an index of impulsivity, reflects individuals' preference for smaller immediate rewards to larger delayed rewards. The current study examined (a) relations between DD and quantity, frequency, and severity of Cannabis use, as well as several other measures of co-occurring substance use and clinical severity, and (b) whether DD predicted Cannabis-cessation outcomes. Cannabis-dependent United States (U.S.) veterans (N = 72; 95% male) who were interested in making serious self-quit attempts were evaluated prior to their cessation attempts, during which they completed a computerized DD task, and were followed throughout six months postattempt. Results indicated that higher DD was significantly correlated with higher compulsive craving for Cannabis (ρ = .29, p < .05), younger age of first Cannabis use (r = -.32, p < .01), earlier commencement of regular Cannabis smoking (r = -.25, p < .05), and seeking professional help for a previous Cannabis quit attempt (ρ = .27, p < .05). DD did not significantly predict any Cannabis-cessation outcomes in the first week postattempt or during the 6-month follow-up. These results add to the literature on DD, which has focused on users of tobacco, alcohol, opioids, and cocaine, by demonstrating that DD is sensitive to developmental trajectories of Cannabis dependence, but does not reliably predict cessation outcomes. Results also suggest that DD may carry less relevance for Cannabis than for other substances of abuse.

Sleep quality among U.S. military veterans with PTSD: a factor analysis and structural model of symptoms

Poor sleep quality among individuals with posttraumatic stress disorder (PTSD) is associated with poorer prognosis and outcomes. The factor structure of the most commonly employed measure of self-reported sleep quality, the Pittsburgh Sleep Quality Index (PSQI), has yet to be evaluated among individuals with PTSD. The current study sought to fill this gap among a sample of 226 U.S. military veterans with PTSD (90% with co-occurring mood disorders, 73.5% with substance use disorders). We evaluated the factor structure of the PSQI by conducting an exploratory factor analysis (EFA) in approximately half of the sample (n = 111). We then conducted a second EFA in the other split half (n = 115). Lastly, we conducted a path analysis to investigate the relations between sleep factors and PTSD symptom severity, after accounting for the relation with depression. Results suggested sleep quality can best be conceptualized, among those with PTSD, as a multidimensional construct consisting of 2 factors, Perceived Sleep Quality and Efficiency/Duration. After accounting for the association between both factors and depression, only the Perceived Sleep Quality factor was associated with PTSD (β = .51). The results provide a recommended structure that improves precision in measuring sleep quality among veterans with PTSD.

The underdiagnosis of cannabis use disorders and other Axis-I disorders among military veterans within VHA

Recent evidence suggests that rates of cannabis use disorders are significantly lower among military veterans within the Veterans Affairs Health Care System (VA) than the general U.S. population. However, prevalence rates obtained from the VA rely on clinician diagnosis, which have been shown to be underrepresentative of actual disorder rates. The present study utilized structured clinical interviews to assess a sample of 84 military veterans with a cannabis use disorder and compared Axis-I disorder diagnosis rates to those obtained through a retrospective electronic medical record chart review. Findings indicated that cannabis use disorders, as well as posttraumatic stress disorder and other anxiety disorders, were significantly underdiagnosed within this military veteran population. In contrast, rates of other substance use disorders as well as mood disorders were overdiagnosed within this VA population. Findings are discussed in relation to the improvement of screening and repeated structured assessment of military veterans within the VA.