Prevalence and correlates of cannabis use in an outpatient VA posttraumatic stress disorder clinic

Using Passive and Active Data to Predict Post-Traumatic Stress Disorder Symptoms and Cannabis Use in Recently Discharged UK Veterans: A Protocol for the MAVERICK Feasibility Study

Introduction

Post-traumatic stress disorder (PTSD) and comorbid cannabis use disorder (CUD) is a growing concern amongst UK veterans. Co-occurrence of problematic cannabis use, and PTSD is associated with greater PTSD symptom severity, decreased likelihood of cannabis use cessation, worse clinical outcomes, and increased societal burden. Despite increased screening efforts among veterans, there are no effective strategies for predicting risk for PTSD and problematic drug use escalation before these conditions develop, worsen, or become chronic.

Methods

This feasibility study employs a 4-week (28 day) longitudinal design (daily data collection), multiple passive data collection features via a bespoke study smartphone app called MAVERICK, and active data collection via wearable technology to predict clinically meaningful escalations in cannabis use and PTSD symptoms in UK veterans. Questionnaire data will be collected between 06:00 and 10:00 each day. Passive data will be collected continuously in the background.

Results

The study will begin recruitment in June 2023 and will require 18 months to complete. Study results are expected to be published in January 2024.

Discussion

This trial will provide information on the feasibility and utility of a smartphone app (MAVERICK) to collect both active and passive data to predict PTSD symptoms and cannabis use in a UK veteran population. If the smartphone app is deemed feasible and acceptable to users, it has the potential to provide an effective measurement tool to mitigate risk of PTSD and problematic cannabis use among veterans.

Genome-wide DNA methylation analysis of cannabis use disorder in a veteran cohort enriched for posttraumatic stress disorder

Cannabis use has been increasing over the past decade, not only in the general US population, but particularly among military veterans. With this rise in use has come a concomitant increase in cannabis use disorder (CUD) among veterans. Here, we performed an epigenome-wide association study for lifetime CUD in an Iraq/Afghanistan era veteran cohort enriched for posttraumatic stress disorder (PTSD) comprising 2,310 total subjects (1,109 non-Hispanic black and 1,201 non-Hispanic white). We also investigated CUD interactions with current PTSD status and examined potential indirect effects of DNA methylation (DNAm) on the relationship between CUD and psychiatric diagnoses. Four CpGs were associated with lifetime CUD, even after controlling for the effects of current smoking (AHRR cg05575921, LINC00299 cg23079012, VWA7 cg22112841, and FAM70A cg08760398). Importantly, cg05575921, a CpG strongly linked to smoking, remained associated with lifetime CUD even when restricting the analysis to veterans who reported never smoking cigarettes. Moreover, CUD interacted with current PTSD to affect cg05575921 and cg23079012 such that those with both CUD and PTSD displayed significantly lower DNAm compared to the other groups. Finally, we provide preliminary evidence that AHRR cg05575921 helps explain the association between CUD and any psychiatric diagnoses, specifically mood disorders.

Unhealthy behaviors associated with mental health disorders: a systematic comparative review of diet quality, sedentary behavior, and cannabis and tobacco use

Background

There are well-established literatures documenting the associations between mental disorders and unhealthy behaviors such as poor diet quality, sedentary behavior, and cannabis and tobacco use. Few studies have attempted to understand the respective findings in light of each other, however.

Objective

The purpose of this review was to assemble comparable data for each behavior-disorder association and assess the associations in terms of their overall strength. The review aimed to include a representative, but not exhaustive, range of studies that would allow for explorative comparisons.

Methods

Eligible studies were identified via Pubmed searches and citation searching, restricted to publications no older than 2015 written in English. To obtain comparable data, only studies that reported findings as odds ratios were included, and risk of bias related to study samples, behavioral measurement disparities, and control variables was assessed via sensitivity analyses. Findings for each disorder were compared on the basis of different measures of central tendency.

Results

From 3,682 records, 294 studies were included. The review found evidence of associations between each of the four unhealthy behaviors and psychosis, depression, anxiety, bipolar disorder, attention-deficit/hyperactivity disorder (ADHD), and post-traumatic stress disorder (PTSD), while personality disorder was only investigated in relation to cannabis and tobacco use. In overall comparison, the associations were generally of similar strength, and only the association between cannabis use and personality disorder was exceptional in terms of being significantly stronger than its counterparts across disorders and across behaviors. Analyses of bias risk identified some influence from behavioral measurement disparities and lack of adequate statistical control, but findings were generally robust across a range of sensitivity analyses.

Conclusion

This explorative and comparative review found that poor diet quality, sedentary behavior, and cannabis and tobacco use are about equally strongly associated with a range of different mental disorders. Given the general nature of these associations, we should probably understand them to reflect a general and shared etiology. However, the findings in this review should be regarded as tentative until confirmed by more comprehensive investigations.

Development of Mobile Contingency Management for Cannabis Use Reduction

Many interventions for cannabis use disorder (CUD) are associated with decreases in frequency and quantity of use but fail to increase overall rates of sustained abstinence. It is currently unknown whether reductions in use (in the absence of sustained abstinence) result in clinically significant improvements in functioning. The objective of this study was to refine a mobile contingency management approach to reduce cannabis use to ultimately evaluate whether reductions in frequency and quantity of cannabis are related to improvements in functional and mental health status. Three cohorts of participants (n = 18 total, n = 10 women) were enrolled and completed 2 weeks of ecological momentary assessment (EMA) during a baseline ad lib cannabis use period, followed by a 6-week reduction period. Participants completed EMA assessments multiple times per day and were prompted to provide videotaped saliva cannabis testing 2-3 times daily. Data from participants who were at least 80% adherent to all EMA prompts were analyzed (13 out of 18). During the ad lib phase, participants were using cannabis on 94% of the days and reported using a mean of 1.42 grams daily. The intervention was a mobile application that participants used to record cannabis use by saliva tests to bioverify abstinence and participants completed electronic diaries to report their grams used. During the 6-week intervention phase, participants reported reducing their use days to 47% of the days with a reported mean of .61 grams daily. In the last cohort, at least 50% of the heavy users were able to reduce their cannabis use by at least 50%. The effect of cannabis reduction (versus abstinence) is largely unknown. Observations suggest that it is possible to develop a mobile intervention to reduce cannabis use among heavy users, and this paradigm can be utilized in future work to evaluate whether reductions in cannabis use among heavy users will result in improvements in functional and mental health status.

Correlates of cannabis use in a sample of mental health treatment-seeking Canadian armed forces members and veterans

OBJECTIVE

Canadian Armed Forces (CAF) members and Veterans are more likely to experience mental health (MH) conditions, such as posttraumatic stress disorder (PTSD), than the general Canadian population. Previous research suggests that an increasing number of individuals are employing cannabis for MH symptom relief, despite a lack of robust evidence for its effectiveness in treating PTSD. This research aimed to: (1) describe the prevalence of current cannabis use among MH treatment-seeking CAF members and Veterans; and (2) estimate the association between current cannabis use and a number of sociodemographic, military, and MH-related characteristics.

METHOD

Using cross-sectional intake data from 415 CAF members and Veterans attending a specialized outpatient MH clinic in Ontario, Canada, between January 2018 and December 2020, we estimated the proportion of CAF members and Veterans who reported current cannabis use for either medical or recreational purposes. We used multivariable logistic regression to estimate adjusted odds ratios for a number of sociodemographic, military, and MH-related variables and current cannabis use.

RESULTS

Almost half of the study participants (n = 187; 45.1%) reported current cannabis use. Respondents who reported current cannabis use for medical purposes had a higher median daily dose than those who reported current cannabis use for recreational purposes. The multivariable logistic regression identified younger age, lower income, potentially hazardous alcohol use, and increased bodily pain as statistically significant correlates of current cannabis use among our MH treatment-seeking sample. PTSD severity, depressive severity, sleep quality, and suicide ideation were not statistically associated with current cannabis use.

CONCLUSIONS

Almost half of our treatment-seeking sample reported current cannabis use for medical or recreational purposes, emphasizing the importance of screening MH treatment-seeking military members and Veterans for cannabis use prior to commencing treatment. Future research building upon this study could explore the potential impact of cannabis use on MH outcomes.

Use of Electronic Cigarettes and Other Tobacco Products Among Active Component Services Members

INTRODUCTION

e-cigarettes have been touted as a safer alternative to classic cigarettes and other combustible tobacco products. However, a growing body of evidence finds that any risk reduction associated with e-cigarette use is eliminated when individuals use "both" e-cigarettes and other tobacco products. Recent analyses from the Health Related Behaviors Survey suggest that rates of e-cigarette use are higher among active component service members than in the general population. However, little is known about the frequency and health behaviors associated with the dual use of e-cigarettes and other tobacco products among service members.

DATA AND METHOD

Using data from the 2018 Health Related Behaviors Survey, this paper investigates whether active component service members who use both e-cigarettes and other tobacco products are more likely to engage in other types of substance use or negative health behaviors.

RESULTS

We find that the dual use of e-cigarettes and other tobacco products is associated with poorer physical and mental health, higher rates of alcohol misuse, and higher rates of insufficient sleep.

CONCLUSION

The association between the dual use of e-cigarettes and tobacco products suggests that these individuals represent an important target group for health-related resources and attention in DoD.

Ecological Momentary Assessment of Cannabis Use and Affect Among Adolescents Following Psychiatric Discharge

OBJECTIVE

Affect regulation is central to multiple theoretical models that explain cannabis use (CU) behavior. However, much of the research has been conducted with adults, leaving unanswered questions about the nature of associations among adolescents, especially those with affective disorders. Using clinical interviews and ecological momentary assessment (EMA), we assessed rates of adolescent CU and momentary associations with affect following psychiatric discharge among youth hospitalized for suicidal thoughts and behaviors.

METHOD

Participants were 13- to 18-year-olds (N = 62; 64.5% female) recruited from an inpatient psychiatric hospital who reported having ever used cannabis. Participants completed clinical interviews during hospitalization. EMA was conducted for 21 days upon discharge.

RESULTS

Concurrent use of other drugs was associated with greater odds of CU (odds ratio = 27.63). Momentary CU was associated with higher levels of positive affect and lower levels of anger/irritability, but not with negative affect. The effect of momentary CU on positive affect was greater among youth with a diagnosis of posttraumatic stress disorder (PTSD) or generalized anxiety disorder (GAD).

CONCLUSIONS

Findings suggest that adolescents may use cannabis to enhance positive emotion, especially those with PTSD/GAD. Results highlight the importance of tailored interventions that focus on providing alternative and adaptive methods to enhance positive affect.

The association between recreational cannabis use and posttraumatic stress disorder: A systematic review and methodological critique of the literature

BACKGROUND

Given recent changes in the legal status of cannabis, the risks and benefits associated with its use have become an important public health topic. A growing body of research has demonstrated that posttraumatic stress disorder (PTSD) and recreational cannabis use (RCU) frequently co-occur, yet findings are inconsistent (e.g., direction of effect) and methodological variability makes comparison across studies difficult.

METHODS

We conducted a comprehensive systematic review of all studies (N = 45) published before May 2020 regarding etiologic models of co-occurring RCU and PTSD, as well as provided a methodological critique to inform suggestions for future research initiatives.

RESULTS

Findings indicate that a majority of studies (n = 37) demonstrated a significant association between RCU and PTSD. Findings provide evidence for the self-medication and high-risk models posited to explain co-occurring RCU and PTSD despite variability in assessment of RCU, which includes commonly used non-standardized self-report questions.

CONCLUSION

The association between RCU and PTSD is likely bidirectional. Results inform clinicians and researchers working in the mental health and cannabis use fields how the variability in findings on the association between RCU and PTSD may be attributable, in part, to methodological issues that permeate the extant literature pertaining to RCU and PTSD.

Patient Perspectives on Medical Trauma Related to Inflammatory Bowel Disease

Post-traumatic stress symptoms (PTSS) in response to medical trauma are understudied in inflammatory bowel disease (IBD). Two studies identify surgery, hospitalizations, and disease severity as risk factors. We aimed to document IBD-related patient experiences and how these relate to PTSS via a qualitative study. Adult patients with confirmed IBD recruited from two gastroenterology clinics underwent a semi-structured interview with a psychologist and completed the Post Traumatic Stress Disorder Symptom Scale for DSM5 (PSSI-5). Interviews were analyzed using an interpretive phenomenological approach. Themes and subthemes with representative quotations were documented based on thematic saturation. 16 participants, five met PSSI-5 criteria for PTSD. Five themes emerged: disease uncertainty, information exchange/quality, medical procedures, surgery, and coping. Patients with IBD may experience medical PTSS from several sources. Information, communication, and trust in clinicians is vital but may be sub-optimal. Both adaptive and maladaptive coping strategies are used to mitigate PTSS.

Effects of Cannabis on PTSD Recovery: Review of the Literature and Clinical Insights

Purpose of Review

Individuals with posttraumatic stress disorder (PTSD) may use cannabis to reduce symptoms yet are also at risk for developing problematic use. This review outlines theories, summarizes recent empirical studies, and discusses clinical implications of cannabis use and PTSD recovery.

Recent Findings

Although naturalistic studies and open trials find a relationship between cannabinoids and PTSD symptom reduction, methodological limitations preclude definitive conclusions. The only randomized controlled trial to date found cannabis had no greater effect on PTSD symptoms than placebo.

Summary

Rigorous studies of the long-term impact of cannabis use on PTSD recovery are needed. Clinicians and researchers must weigh the potential therapeutic effect against the costs and risks associated with long-term cannabis use. Clinicians should consider all available PTSD treatment options, along with client level factors such as the function of cannabis use, motivation to change use, and the potential impact of cannabis on treatment engagement when making clinical recommendations.

Hospitalization Experiences and Post-traumatic Stress in Inflammatory Bowel Disease: Opportunities for Change

INTRODUCTION

Medical trauma related to IBD (IBD-PTS) affects approximately 25% of patients and is associated with poor outcomes. Prior studies identify common hospitalization experiences as potentially traumatic but have not measured risk relationships for the development of IBD-PTS. We aim to investigate what aspects of hospitalizations may increase the chance of medical trauma and IBD-PTS development.

METHODS

Adult patients with IBD enrolled in the IBD Partners database were recruited. Study specific questionnaires included PTSD checklist, 5th edition (PCL-5), patient experience questionnaire, and items about the patient's most stressful hospitalization and nonhospital sources of medical trauma. Established criteria for the PCL-5 identified significant IBD-PTS symptoms (re-experiencing, avoidance, mood change, hyperarousal, global diagnosis). Select disease and treatment information was obtained from the main IBD Partners dataset. Univariate and multivariate statistics evaluated the relationships between hospitalization data and IBD-PTS.

RESULTS

There were 639 participants with at least 1 hospitalization for IBD included. Approximately two-thirds had Crohn's disease; most were White, non-Hispanic, female, middle-aged, and reported their IBD as being in remission. Forty percent of patients stated a hospitalization was a source of IBD-PTS. Frequent anxiety while hospitalized increased the odds of IBD-PTS 2 to 4 times; similar relationships existed for pain/pain control. Higher quality communication, information, and listening skills reduced the odds of IBD-PTS, albeit marginally.

CONCLUSIONS

Patients with IBD consistently cite hospitalizations as potential sources of medical trauma. Poorly managed anxiety and pain demonstrate the greatest chance for IBD-PTS development. Gender and racial/ethnic differences emerged for these risks. Positive interactions with the medical team may help mitigate in-hospital IBD-PTS development.

Longitudinal course of mental health symptoms among veterans with and without cannabis use disorder

OBJECTIVE

Cannabis use disorder (CUD) is the most common non-alcohol related substance use disorder (SUD) in the United States and is especially prevalent among returning veterans. The long-term mental health correlates of CUD remain unknown, which is significant given the rise in legalization and also recreational and medicinal cannabis use nationally.

METHOD

Using a gender-balanced, national sample of 1,649 veterans (n = 115 with CUD; 75.2% White; M age = 37.49, SD = 9.88), we used latent growth curve modeling to examine posttraumatic stress disorder (PTSD) symptom severity, depressive symptoms, generalized anxiety, alcohol use, and psychosocial functioning between veterans with versus without a prior diagnosis of CUD over five time points, spanning an average of 7 years.

RESULTS

Returning veterans with CUD compared to those without reported higher alcohol use, depression, anxiety, PTSD symptom severity, and worse psychosocial functioning at baseline. We observed nonlinear change across each outcome. We also found that CUD moderated change in alcohol use (quadratic: b = -.129, p < .001) and PTSD symptoms (quadratic: b = -.280, p = .019), such that individuals with CUD evidenced decelerated change and worse outcomes relative to veterans without a previously documented CUD diagnosis. Trajectories of depression, anxiety, and psychosocial functioning were similar across individuals with versus without CUD.

CONCLUSIONS

In the first long-term and longitudinal evaluation of mental health and alcohol use course among returning veterans, CUD was associated with worse and more persistent alcohol use and PTSD symptom severity over time. These data have implications for clinical assessment, case conceptualization, and treatment of veterans and may inform efforts to offset risk for hazardous drinking and PTSD following a diagnosis of CUD. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Cannabis and Mental Health: Adverse Outcomes and Self-Reported Impact of Cannabis Use by Mental Health Status

Background: Cannabis can induce negative outcomes among consumers with mental health conditions. This study examined medical help-seeking behavior, patterns of adverse effects, and perceived impacts of cannabis among consumers with and without mental health conditions. Methods: Data came from the International Cannabis Policy Study, via online surveys conducted in 2018. Respondents included 6,413 past 12-month cannabis consumers aged 16-65, recruited from commercial panels in Canada and the US. Regression models examined differences in adverse health effects and perceived impact of cannabis among those with and without self-reported past 12-month experience of anxiety, depression, PTSD, bipolar disorder, psychosis. Results: Overall, 7% of past 12-month consumers reported seeking medical help for adverse effects of cannabis, including panic, dizziness, nausea. Help-seeking was greater for those with psychosis (13.8%: AOR = 1.78; 1.11-2.87), depression (8.9%: AOR = 1.57; 1.28-1.93), and bipolar disorder (10.1%: AOR = 1.53; 1.44-2.74). Additionally, 54.1% reported using cannabis to manage symptoms of mental health, with higher rates among those with bipolar (90.8%) and PTSD (90.7%). Consumers reporting >1 condition were more likely to perceive positive impacts on friendships, physical/mental health, family life, work, studies, quality of life (all p < .001). Consumers with psychosis were most likely to perceive negative effects across categories. Conclusion: For conditions with substantial evidence suggesting cannabis is harmful, greater help-seeking behaviors and self-perceived negative effects were observed. Consumers with mental health conditions generally perceive cannabis to have a positive impact on their lives. The relationship between cannabis and mental health is disorder specific and may include a combination of perceived benefits and harms.

Prevalence and Correlates of Cannabis Use and Cannabis Use Disorder Among U.S. Veterans: Results From the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III)

OBJECTIVE

The authors sought to estimate the prevalence of past-12-month and lifetime cannabis use and cannabis use disorder among U.S. veterans; to describe demographic, substance use disorder, and psychiatric disorder correlates of nonmedical cannabis use and cannabis use disorder; and to explore differences in cannabis use and cannabis use disorder prevalence among veterans in states with and without medical marijuana laws.

METHODS

Participants were 3,119 respondents in the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III) who identified as U.S. veterans. Weighted prevalences were calculated. Logistic regression analyses tested associations of nonmedical cannabis use and cannabis use disorder with demographic and clinical correlates and examined whether prevalence differed by state legalization status.

RESULTS

The prevalences of any past-12-month cannabis use and cannabis use disorder were 7.3% and 1.8%, respectively. Lifetime prevalences were 32.5% and 5.7%, respectively. Past-12-month and lifetime cannabis use disorder prevalence estimates among nonmedical cannabis users were 24.4% and 17.4%, respectively. Sociodemographic correlates of nonmedical cannabis use and use disorder included younger age, male gender, being unmarried, lower income, and residing in a state with medical marijuana laws. Nonmedical cannabis use and use disorder were associated with most psychiatric and substance use disorders examined.

CONCLUSIONS

Among veterans, the odds of nonmedical cannabis use and use disorder were elevated among vulnerable subgroups, including those with lower income or psychiatric disorders and among survey participants residing in states with medical marijuana laws. The study findings highlight the need for clinical attention (e.g., screening, assessment) and ongoing monitoring among veterans in the context of increasing legalization of cannabis.

Changes in alcohol use during the COVID-19 pandemic among American veterans

BACKGROUND

The COVID-19 pandemic has had considerable behavioral health implications globally. One subgroup that may be of particular concern is U.S. veterans, who are susceptible to mental health and substance use concerns. The current study aimed to investigate changes in alcohol use and binge drinking before and during the first year of the pandemic among U.S. veterans, and how pre-pandemic mental health disorders, namely posttraumatic stress disorder (PTSD), and COVID-19-related factors like loneliness, negative reactions to COVID-19, and economic hardship influenced alcohol use trends.

METHODS

1230 veterans were recruited in February 2020 as part of a larger survey study on veteran health behaviors. Veterans were asked to complete follow-up assessments throughout the pandemic at 6, 9, and 12- months.

RESULTS

Overall, veterans reported a significant decrease in alcohol use (IRR = 0.98) and binge drinking (IRR = 0.11) However, women, racial/ethnic minority veterans, and those with pre-existing PTSD exhibited smaller decreases in alcohol use and binge drinking and overall higher rates of use compared to men, White veterans, and those without PTSD. Both economic hardship and negative reactions to COVID-19 were associated with greater alcohol and binge drinking whereas loneliness showed a negative association with alcohol use and binge drinking.

CONCLUSIONS

Veterans reported decreases in alcohol use and binge drinking throughout the pandemic, with heterogeneity in these outcomes noted for higher risk groups. Special research and clinical attention should be given to the behavioral health care needs of veterans in the post-pandemic period.

Imaging brain cortisol regulation in PTSD with a target for 11β-hydroxysteroid dehydrogenase type 1

BACKGROUNDInvestigations of stress dysregulation in posttraumatic stress disorder (PTSD) have focused on peripheral cortisol, but none have examined cortisol in the human brain. This study used positron emission tomography (PET) to image 11β-hydroxysteroid dehydrogenase type 1 (11β-HSD1), a cortisol-producing enzyme, as a putative brain cortisol marker in PTSD.METHODSSixteen individuals with PTSD and 17 healthy, trauma-exposed controls (TCs) underwent PET imaging with [18F]AS2471907, a radioligand for 11β-HSD1.RESULTSPrefrontal-limbic 11β-HSD1 availability, estimated as [18F]AS2471907 volume of distribution (VT), was significantly higher in the PTSD group compared with the TC group (β = 1.16, P = 0.0057). Lower prefrontal-limbic 11β-HSD1 availability was related to greater overall PTSD severity (R2 = 0.27, P = 0.038) in the PTSD group. 11β-HSD1 availability was not related to plasma cortisol levels (R2 = 0.026, P = 0.37). In a PTSD subset (n = 10), higher 11β-HSD1 availability was associated with higher availability of translocator protein (TSPO), a microglial marker (β = 4.40, P = 0.039).CONCLUSIONHigher brain cortisol-producing 11β-HSD1 in the PTSD group may represent a resilience-promoting neuroadaptation resulting in lower PTSD symptoms. Along with preliminary associations between 11β-HSD1 and TSPO, corroborating previous evidence of immune suppression in PTSD, these findings collectively challenge previous hypotheses of the deleterious effects of both excessive brain glucocorticoid and brain immune signaling in PTSD.FUNDINGBrain and Behavior Research Foundation Independent Investigator Grant, National Institute of Mental Health grants F30MH116607 and R01MH110674, the Veterans Affairs National Center for PTSD, the Gustavus and Louise Pfeiffer Foundation Fellowship, Clinical and Translational Science Awards grant UL1 TR000142 from the NIH National Center for Advancing Translational Science.

Co-use of Tobacco Products and Cannabis among Veterans: A Preliminary Investigation of Prevalence and Associations with Mental Health Outcomes

While tobacco product (such as combustible cigarettes and nicotine vaping products) and cannabis use rates remain high in the general United States (U.S.) population, veterans from the conflicts in Iraq and Afghanistan (i.e., OEF/OIF veterans) are at high risk of high rates of cannabis and tobacco use. Co-use of tobacco and cannabis (i.e., using both substances within a specified period of time or combining the drugs within the same device for use) is of growing prevalence in the U.S. However, little is understood about the prevalence rates of tobacco and cannabis co-use among U.S. veterans and its associations with mental health symptomatology. The current study conducted a preliminary analysis of co-use patterns of tobacco and cannabis and associated mental health outcomes among a sample of OEF/OIF veterans (N = 1,230). Results indicated high rates of lifetime and past 30-day use of both substances. Past 30-day co-users endorsed significantly higher levels of stress, PTSD, depression, and anxiety compared to singular product users. Results suggest that the addition of cannabis use in conjunction with tobacco use may be associated with greater mental health symptoms among veterans. Findings indicate veteran tobacco and cannabis co-users may benefit from mental health care to help mitigate poor mental health symptoms.

Burden of cannabis use and disorder in the U.S. veteran population: Psychiatric comorbidity, suicidality, and service utilization

BACKGROUND

Cannabis use is associated with psychiatric illness and suicidality, which are prevalent among U.S. military veterans. However, the psychiatric burden of cannabis use and cannabis use disorder (CUD) among veterans is unclear. Using data from a nationally representative sample of veterans, we evaluated associations of lifetime cannabis use and CUD with psychiatric problems, suicidality, and treatment utilization.

METHODS

Participants were 3,157 veterans aged 21 to 96 years from the National Health and Resilience in Veterans Study (NHRVS). Cannabis use and CUD were assessed using the Mini International Neuropsychiatric Interview. Psychiatric morbidities, suicidal ideation and attempts, and treatment utilization were assessed and compared between three cannabis groups: [1] no lifetime cannabis use (never-use); [2] lifetime cannabis use but never met criteria for CUD (non-CUD cannabis use); [3] lifetime CUD (CUD).

RESULTS

Relative to the never-use group, veterans who used cannabis had elevated odds of current and lifetime posttraumatic stress disorder (PTSD), mood, anxiety, and substance use disorders, current suicidal ideation, lifetime suicide attempts, and current and lifetime mental health treatment utilization [odds ratios (ORs)=1.5-8.3]. Veterans with CUD had higher odds of current and lifetime PTSD, mood, and anxiety disorders, lifetime nicotine and alcohol dependence, and current suicidal ideation, relative to veterans who used cannabis but never met criteria for CUD (ORs=1.6-2.7).

LIMITATIONS

The cross-sectional design of this study precludes causal inference.

CONCLUSIONS

Cannabis use and CUD are associated with substantial psychiatric and suicide-related burden among veterans, highlighting the need for screening, education, and treatment to mitigate potential cannabis-related harm.

2-Arachidonoylglycerol Modulation of Anxiety and Stress Adaptation: From Grass Roots to Novel Therapeutics

Over the past decade there has been a surge of interest in the development of endocannabinoid-based therapeutic approaches for the treatment of diverse neuropsychiatric conditions. Although initial preclinical and clinical development efforts focused on pharmacological inhibition of fatty acid amide hydrolase to elevate levels of the endocannabinoid anandamide, more recent efforts have focused on inhibition of monoacylglycerol lipase (MAGL) to enhance signaling of the most abundant and efficacious endocannabinoid ligand, 2-arachidonoylglycerol (2-AG). We review the biochemistry and physiology of 2-AG signaling and preclinical evidence supporting a role for this system in the regulation of anxiety-related outcomes and stress adaptation. We review preclinical evidence supporting MAGL inhibition for the treatment of affective, trauma-related, and stress-related disorders; describe the current state of MAGL inhibitor drug development; and discuss biological factors that could affect MAGL inhibitor efficacy. Issues related to the clinical advancement of MAGL inhibitors are also discussed. We are cautiously optimistic, as the field of MAGL inhibitor development transitions from preclinical to clinical and theoretical to practical, that pharmacological 2-AG augmentation could represent a mechanistically novel therapeutic approach for the treatment of affective and stress-related neuropsychiatric disorders.

Clinical Data for the Use of Cannabis-Based Treatments: A Comprehensive Review of the Literature

Objective:

To compile and synthesize the available literature describing medical cannabis use across various disease states.

Data Sources:

PubMed, EBSCO, and Google Scholar searches were conducted using MeSH and/or keywords.

Study Selection and Data Extraction:

Studies were included if they described the use of cannabis-based products and medications in the treatment of a predefined list of disease states in humans and were published in English. The extraction period had no historical limit and spanned through April 2019.

Data Synthesis:

Evidence was compiled and summarized for the following medical conditions: Alzheimer disease, amyotrophic lateral sclerosis, autism, cancer and cancer-associated adverse effects, seizure disorders, human immunodeficiency virus, inflammatory bowel disease, multiple sclerosis (MS), nausea, pain, posttraumatic stress disorder, and hospice care.

Relevance to Patient Care and Clinical Practice:

Based on identified data, the most robust evidence suggests that medical cannabis may be effective in the treatment of chemotherapy-induced nausea and vomiting, seizure disorders, MS-related spasticity, and pain (excluding diabetic neuropathy). Overall, the evidence is inconsistent and generally limited by poor quality. The large variation in cannabis-based products evaluated in studies limits the ability to make direct comparisons. Regardless of the product, a gradual dose titration was utilized in most studies. Cannabis-based therapies were typically well tolerated, with the most common adverse effects being dizziness, somnolence, dry mouth, nausea, and euphoria.

Conclusions:

As more states authorize medical cannabis use, there is an increasing need for high-quality clinical evidence describing its efficacy and safety. This review is intended to serve as a reference for clinicians, so that the risks and realistic benefits of medical cannabis are better understood.

Does cannabis use modify the effect of post-traumatic stress disorder on severe depression and suicidal ideation? Evidence from a population-based cross-sectional study of Canadians

BACKGROUND

Post-traumatic stress disorder sharply increases the risk of depression and suicide. Individuals living with post-traumatic stress disorder frequently use cannabis to treat associated symptoms. We sought to investigate whether cannabis use modifies the association between post-traumatic stress disorder and experiencing a major depressive episode or suicidal ideation.

METHODS

We used data from the 2012 Canadian Community Health Survey-Mental Health, a nationally representative cross-sectional survey of non-institutionalized Canadians aged ⩾15 years. The relationship between post-traumatic stress disorder and each outcome was modelled using logistic regression with an interaction term for cannabis and post-traumatic stress disorder, controlling for demographic characteristics, mental health, and substance use comorbidities. The ratio of odds ratios and relative excess risk due to interaction was calculated to measure interaction on the multiplicative and additive scales, respectively.

RESULTS

Among 24,089 eligible respondents, 420 (1.7%) reported a current clinical diagnosis of post-traumatic stress disorder. In total, 106 (28.2%) people with post-traumatic stress disorder reported past-year cannabis use, compared to 11.2% of those without post-traumatic stress disorder (p < 0.001). In multivariable analyses, post-traumatic stress disorder was significantly associated with recent major depressive episode (adjusted odds ratio = 7.18, 95% confidence interval: 4.32-11.91) and suicidal ideation (adjusted odds ratio = 4.76, 95% confidence interval: 2.39-9.47) among cannabis non-users. post-traumatic stress disorder was not associated with either outcome among cannabis-using respondents (both p > 0.05).

CONCLUSIONS

This study provides preliminary epidemiological evidence that cannabis use may contribute to reducing the association between post-traumatic stress disorder and severe depressive and suicidal states. There is an emerging need for high-quality experimental investigation of the efficacy of cannabis/cannabinoids for the treatment of post-traumatic stress disorder.

Cannabis Use Disorder and Post-Deployment Suicide Attempts in Iraq/Afghanistan-Era Veterans

The objective of the present study was to use retrospective data to test the hypothesis that cannabis dependence would be associated with an increased rate of post-deployment suicide attempts. Participants included 319 veterans who had deployed to either Iraq or Afghanistan. Study procedures involved completion of a structured clinical interview and a battery of self-report questionnaires. As expected, lifetime cannabis dependence was significantly associated with post-deployment suicide attempts, AOR = 7.963, p = .014, even after controlling for the effects of pre-deployment suicide attempts, posttraumatic stress disorder, depression, pain, non-cannabis substance use disorder, and gender. Although preliminary, our findings provide the first evidence to date that heavy cannabis use may be a unique risk factor for post-deployment suicide attempts among veterans.

Patterns and predictors of self-harm in patients with substance-use disorder

BACKGROUND

Suicide is a growing health concern and causes significant health burden. Patients with substance use disorders represent an especially vulnerable population in terms of self-harm. Data on risk factors for self-harm in substance-using population in the Indian context are limited. We aimed to determine the patterns and sociodemographic/clinical predictors of self-harm in patients with substance use disorders.

MATERIALS AND METHODS

We assessed 300 male patients on Deliberate Self-Harm Inventory to assess the patterns of self-harm. We performed mediation analysis to determine whether clinical variables acted via sociodemographic variables in their effect on self-harm.

RESULTS

The occurrence rate of self-harm was 32.7%. It was significantly associated with a younger age, being unmarried/separated, unemployed, history of injecting drug use, high-risk sexual behavior, and cannabis use disorders.

CONCLUSION

Self-harm is an important consideration among patients with substance use disorders, and needs to be addressed by the clinicians involved in the care of such patients.

Novel pharmacological targets in drug development for the treatment of anxiety and anxiety-related disorders

Current medication for anxiety disorders is suboptimal in terms of efficiency and tolerability, highlighting the need for improved drug treatments. In this review an overview of drugs being studied in different phases of clinical trials for their potential in the treatment of fear-, anxiety- and trauma-related disorders is presented. One strategy followed in drug development is refining and improving compounds interacting with existing anxiolytic drug targets, such as serotonergic and prototypical GABAergic benzodiazepines. A more innovative approach involves the search for compounds with novel mechanisms of anxiolytic action using the growing knowledge base concerning the relevant neurocircuitries and neurobiological mechanisms underlying pathological fear and anxiety. The target systems evaluated in clinical trials include glutamate, endocannabinoid and neuropeptide systems, as well as ion channels and targets derived from phytochemicals. Examples of promising novel candidates currently in clinical development for generalised anxiety disorder, social anxiety disorder, panic disorder, obsessive compulsive disorder or post-traumatic stress disorder include ketamine, riluzole, xenon with one common pharmacological action of modulation of glutamatergic neurotransmission, as well as the neurosteroid aloradine. Finally, compounds such as D-cycloserine, MDMA, L-DOPA and cannabinoids have shown efficacy in enhancing fear-extinction learning in humans. They are thus investigated in clinical trials as an augmentative strategy for speeding up and enhancing the long-term effectiveness of exposure-based psychotherapy, which could render chronic anxiolytic drug treatment dispensable for many patients. These efforts are indicative of a rekindled interest and renewed optimism in the anxiety drug discovery field, after decades of relative stagnation.

Use of Medicinal Cannabis and Synthetic Cannabinoids in Post-Traumatic Stress Disorder (PTSD): A Systematic Review

Background and Objectives: Post-traumatic stress disorder (PTSD) is a common psychiatric disorder resulting from a traumatic event, is manifested through hyperarousal, anxiety, depressive symptoms, and sleep disturbances. Despite several therapeutic approaches being available, both pharmacological and psychological, recently a growing interest has developed in using cannabis and synthetic cannabinoids stems from their consideration as more efficient and better tolerated alternatives for the treatment of this condition. The present paper aims to evaluate the clinical and therapeutic potentials of medical cannabis and synthetic cannabinoids in treating PTSD patients. Methods: A systematic electronic search was performed, including all papers published up to May 2019, using the following keywords (((cannabis[Title/Abstract]) OR (synthetic cannabinoids [Title/Abstract])) AND ((PTSD[Title/Abstract]) OR (Posttraumatic stress disorder[Title/Abstract]))) for the topics ‘Cannabis’, ‘Synthetic Cannabinoids’, ‘PTSD’, and MESH terms, on the PubMed, Cochrane Library, and Web of Science online databases. For data gathering purposes, PRISMA guidelines were followed. Results were organized into two groups, considering cannabis and synthetic cannabinoids as different therapeutic approaches for PTSD. Results: Present data show that cannabis and synthetic cannabinoids, both acting on the endocannabinoids system, may have a potential therapeutic use for improving PTSD symptoms, e.g., reducing anxiety, modulating memory-related processes, and improving sleep. Conclusions: Even though the current literature suggests that cannabis and synthetic cannabinoids may have a role in the treatment of PTSD, there is currently limited evidence regarding their safety and efficacy. Therefore, additional research is needed in order to better understand the effectiveness and therapeutic usage of these drug classes and monitor their safety.

A cross-sectional examination of choice and behavior of veterans with access to free medicinal cannabis

Background: With a rise in public pressure to increase veteran access to medicinal cannabis, free cannabis collectives for military veterans are proliferating across the US. Objectives: The aim of the current study was to document which cannabis formulations and routes of administration are chosen by veterans with increased access to cannabis, and to determine whether cannabis is being used as a substitute for other licit and illicit drugs. Method: The current study collected cross-sectional self-report data on cannabis use, cannabinoid constituent composition, primary indication of use, and substitution practices among a sample of 93 US military veterans (84.9% male) with access to free cannabis. Result: Most of the sample reported using cannabinoids as a substitute for either alcohol, tobacco, prescription medications, or illicit substances, reported that they use cannabis frequently (Modal frequency >4x/day, Modal quantity = 5 to 8 grams/week), and primarily select higher-risk cannabis formulations (i.e., high THC/low CBD, smoked). The majority of the sample reported that they use cannabis to self-treat multiple physical and mental health conditions/symptoms. Conclusions: Results of the current study suggest that military Veterans with reduced barriers to access cannabis could be making both helpful and harmful choices regarding their cannabis use. These findings suggest that more guidance on the selection of cannabis-based products in this population is warranted, particularly as barriers to medicinal cannabis access are reduced.

The Impact of Cannabis Use Disorder on Suicidal and Nonsuicidal Self-Injury in Iraq/Afghanistan-Era Veterans with and without Mental Health Disorders

The objective of this study was to assess the association between cannabis use disorder (CUD) and self-injury among veterans. As expected, after adjusting for sex, age, sexual orientation, combat exposure, traumatic life events, traumatic brain injury, posttraumatic stress disorder, depression, alcohol use disorder, and noncannabis drug use disorder, CUD was significantly associated with both suicidal (OR = 3.10, p = .045) and nonsuicidal (OR = 5.12, p = .009) self-injury. CUD was the only variable significantly associated with self-injury in all three models examined. These findings are consistent with prior research among civilians and suggest that CUD may also increase veterans' risk for self-injurious behavior.

Medicinal versus Recreational Cannabis Use among Returning Veterans

BACKGROUND

Although increasing rates of cannabis use and cannabis use disorder (CUD) are well-documented among veterans, little is known about their use of cannabis specifically for medicinal purposes. The present study characterizes such use and compares veterans reporting cannabis use for medicinal (n = 66) versus recreational (n = 77) purposes on (a) sociodemographic factors, (b) psychiatric disorders (posttraumatic stress disorder [PTSD], major depressive disorder [MDD], and CUD), (c) other substance use, (d) reasons for cannabis use and cannabis-related problems, and (e) physical and mental health.

METHODS

Participants were veterans deployed post 9/11/2001 recruited from a Veterans Health Administration (VHA) facility (N = 143; mean [SD] age = 30.0 [6.6]; mean [SD] deployments = 1.7 [1.1]) who reported past-year cannabis use.

RESULTS

The most frequently endorsed conditions for medicinal cannabis (MC) use were anxiety/stress, PTSD, pain, depression, and insomnia. In logistic regression analyses adjusted for frequency of cannabis use, MC users were significantly more likely (OR = 3.16) to meet criteria for PTSD than recreational cannabis (RC) users. Relative to RC users, MC users reported significantly greater motivation for using cannabis to cope with sleep disturbance as well as significantly poorer sleep quality and worse physical health.

CONCLUSIONS

Veterans who use cannabis for medicinal purposes differ significantly in sleep, physical and mental health functioning than veterans who use cannabis for recreational purposes. PTSD and sleep problems may be especially relevant issues to address in screening and providing clinical care to returning veterans who are using cannabis for medicinal purposes.

The impact of PTSD clusters on cannabis use in a racially diverse trauma-exposed sample: An analysis from ecological momentary assessment

BACKGROUND

Accumulating evidence indicates a link between post-traumatic stress disorder (PTSD) and cannabis use and suggests that this link may vary as a function of the PTSD symptom cluster type. Consistent with negative reinforcement models of substance use, individuals with elevated Cluster D (Hyperarousal) symptoms may be more likely to use cannabis in response to elevated state anxiety and experience decreases in state anxiety after using cannabis.

OBJECTIVES

We aimed to test hypotheses that the interaction of Cluster D and state anxiety would be related to subsequent cannabis use and that those with elevated Cluster D symptoms who used cannabis would report the greatest decreases in state anxiety. To test the specificity, we tested whether Clusters B (re-experiencing) and C (avoidance) showed similar relationships.

METHODS

The present study used ecological momentary assessment to examine cannabis use among 87 cannabis-using individuals with PTSD symptoms (64.4% male, 56.3% non-Hispanic Caucasian). State anxiety and cannabis use were assessed over the two-week period via signal contingent (six random prompts per day), interval contingent (each bedtime), and event contingent (cannabis use episodes) assessments.

RESULTS

Consistent with negative reinforcement models, participants with clinically significant Cluster D symptoms with elevated state anxiety had a greater likelihood of subsequent cannabis use and cannabis use resulted in less subsequent anxiety. The negative reinforcement hypothesis was only partially supported for those with Cluster B and C symptoms.

CONCLUSIONS

The results suggest that negative reinforcement models may be especially relevant to understanding cannabis use among those with clinically elevated Cluster D symptoms.

Use of Protective Behavioral Strategies among Young Adult Veteran Marijuana Users

Young adult veterans are at risk for problematic marijuana use and associated consequences, which is partially due to their high rates of Posttraumatic Stress Disorder (PTSD), depression, and problematic substance use. Veterans tend to endorse more severe and chronic mental health symptoms compared to their civilian counterparts and they identify marijuana use as a method to cope with their symptoms. Given the prevalence of marijuana use among veterans in the community and in clinical settings, it is important to explore the factors that may help minimize harm associated with use for those that choose to use the drug. The present study sought to examine the impact of protective behavioral strategies on the relationship between mental health symptoms and marijuana use and consequences in a sample of 180 young adult veteran marijuana users. Participants were recruited via social media advertisements and completed measures of marijuana use and consequences, protective behavioral strategies, and PTSD and depression symptoms. Findings indicated that more frequent use of protective behavioral strategies was associated with less marijuana use and consequences. Participants who screened positive for PTSD or depression reported more marijuana consequences than did those not positive on these screeners. Regression analyses revealed protective strategies moderated the relationship between PTSD and marijuana consequences such that young veterans who endorsed more PTSD symptoms and infrequent use of protective strategies reported the most marijuana consequences. No moderating effects were found for the relationship between depression and marijuana consequences. Findings have clinical implications for working with young veterans.

Impact of Cannabis Use on Treatment Outcomes among Adults Receiving Cognitive-Behavioral Treatment for PTSD and Substance Use Disorders

BACKGROUND

Research has demonstrated a strong link between trauma, posttraumatic stress disorder PTSD and substance use disorders (SUDs) in general and cannabis use disorders in particular. Yet, few studies have examined the impact of cannabis use on treatment outcomes for individuals with co-occurring PTSD and SUDs.

METHODS

Participants were 136 individuals who received cognitive-behavioral therapies for co-occurring PTSD and SUD. Multivariate regressions were utilized to examine the associations between baseline cannabis use and end-of-treatment outcomes. Multilevel linear growth models were fit to the data to examine the cross-lagged associations between weekly cannabis use and weekly PTSD symptom severity and primary substance use during treatment.

RESULTS

There were no significant positive nor negative associations between baseline cannabis use and end-of-treatment PTSD symptom severity and days of primary substance use. Cross-lagged models revealed that as cannabis use increased, subsequent primary substance use decreased and vice versa. Moreover, results revealed a crossover lagged effect, whereby higher cannabis use was associated with greater PTSD symptom severity early in treatment, but lower weekly PTSD symptom severity later in treatment.

CONCLUSION

Cannabis use was not associated with adverse outcomes in end-of-treatment PTSD and primary substance use, suggesting independent pathways of change. The theoretical and clinical implications of the reciprocal associations between weekly cannabis use and subsequent PTSD and primary substance use symptoms during treatment are discussed.

Cannabis use among Canadian Armed Forces Veterans

Introduction: Despite rapidly changing cannabis use regulations in Canada, including health care support for Canadian Armed Forces (CAF) Veterans, the prevalence of and reasons for cannabis use in this population have not been studied. Methods: An online 28-item anonymous survey was used to examine the prevalence of cannabis use among CAF Veterans who reported undergoing treatment of PTSD ( N=120). We aimed to estimate the prevalence of cannabis use among CAF Veterans, as well as to explore the reasons for cannabis use in this population. We also examined the relationships between cannabis use and other aspects of health in CAF Veterans, namely other substance use, PTSD symptom severity, and chronic pain severity. Results: Approximately half of the respondents reported a history of cannabis use. Of these, approximately 35.5% reported beginning cannabis use before a military-related trauma, 23% reported beginning after a traumatic event, and 42% reported beginning after release. Participants stated that they used cannabis primarily for relaxation and emotional calm, and for pain management. Only 10% reported its use specifically for PTSD-related symptoms and anxiety. Chronic cannabis users (i.e., one or more years) endorsed a greater number of cannabis abuse symptoms than acute users (i.e., one time to less than three months). Cannabis users were also more likely to use both prescription and non-prescription drugs. No relationships were found between cannabis use and military-related PTSD symptom severity or pain severity. Discussion: Cannabis use, along with other substance use, is common among CAF Veterans, and the reasons for cannabis use vary greatly. Cannabis use does not appear to have an impact on PTSD- and pain-related symptom expression; however, further study is recommended.