Adverse Consequences of Co-Occurring Opioid Use Disorder and Cannabis Use Disorder Compared to Opioid Use Disorder Only

Characteristics of Cannabis and Opioid Users Among Older U.S. Veterans and Their Health Outcomes: A Longitudinal Perspective

Medical cannabis use among U.S. Veterans has continued to rise. However, data on cannabis use by older Veterans is generally less available. This study aims to understand the characteristics of older Veterans who enrolled in the Medical Cannabis Patient Program in Illinois and analyze their health outcomes and co-use of cannabis and opioids using longitudinal survey data. Overall, participants reported positive outcomes for pain, sleep, and emotional problems because of cannabis use in two survey periods. Approximately, 62% and 85% respondents reported no change in memory and falls, respectively, with only 3% and 1% reporting a negative outcome for the conditions in both surveys. About 20.4% of those who indicated cannabis use only in the initial survey started to co-use opioids in the follow-up survey, while 44.1% of those who indicated the use of both substances in the initial survey reported no longer using opioids in the follow-up survey. However, these changes were not statistically significant (α = 0.05 ) . The logistic regression showed that both clinical and contextual factors affected co-use. In conclusion, older U.S. Veterans may be using cannabis to alleviate their pain and other chronic conditions. More research is needed to understand the effect of cannabis use on reducing or substituting opioids.

The impact of cannabis on non-medical opioid use among individuals receiving pharmacotherapies for opioid use disorder: a systematic review and meta-analysis of longitudinal studies

Background: The relationship between cannabis use and the risk of returning to using opioids non-medically during treatment for opioid use disorder (OUD) remains unclear.Objective: We sought to quantify the impact of cannabis use on the risk of non-medical opioid use among people receiving pharmacotherapies for OUD.Methods: A comprehensive search was performed using multiple databases from March 1 to April 5 of 2023. Eligible studies longitudinally assessed the association between cannabis use and non-medical opioid use among people with OUD receiving treatment with buprenorphine, methadone, or naltrexone. We utilized a random-effects model employing the restricted maximum likelihood method. A sensitivity analysis was conducted to understand potential differences between each OUD treatment modality.Results: A total of 10 studies were included in the final meta-analysis. There were 8,367 participants (38% female). The average follow-up time across these studies was 9.7 months (SD = 3.77), ranging from 4 to 15 months. The pharmacotherapies involved were methadone (76.3%) buprenorphine (21.3%), and naltrexone (2.4%). The pooled odds ratio did not indicate that cannabis use significantly influenced non-medical opioid use (OR: 1.00, 95% CI: 0.97-1.04, p = .98). There is evidence of moderate heterogeneity and publication bias.Conclusion: There was no significant association between cannabis use and non-medical opioid use among patients receiving pharmacotherapies for OUD. These findings neither confirm concerns about cannabis increasing non-medical opioid use during MOUD, nor do they endorse its efficacy in decreasing non-medical opioid use with MOUD. This indicates a need for individualized approaches for cannabis use and challenges the requirement of cannabis abstinence to maintain OUD pharmacotherapies.

Screening and Brief Intervention for Cannabis Misuse in Individuals on Buprenorphine Treatment for Opioid Use Disorder: Double-Blind Randomized Clinical Trial

Cannabis misuse and opioid use disorder (OUD) are highly comorbid but under-treated and associated with poorer outcomes. This paper reports a double-blind, parallel-group randomized controlled trial to determine the efficacy of single-session, clinician-delivered screening and brief intervention (SBI) for reducing cannabis risk. The primary outcome was the cannabis-specific Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) scores, measured at three-month post-intervention. The secondary objectives were to determine the efficacy of SBI in reducing the frequency of cannabis use, in risk transition from moderate to low risk, and in prescription and non-prescription opioid use. One hundred forty-three participants were randomly allocated to receive either SBI (n = 72) or control (n = 71) interventions. We performed Per-protocol (PP) (n = 125) and Intention-to-treat (ITT) analysis (n = 143). We adjusted our analysis for age, sex, and baseline ASSIST score. The ITT showed that the SBI group had a significant reduction (F = 39.46, p < .001, Effect size 0.22) in the mean ASSIST at follow-up. PP analyses too revealed a similar positive effect of SBI (F = 53.1; p < .001, Effect size 0.31). At follow-up, the SBI group had a higher number of days of cannabis abstinence. Care providers and policymakers may consider SBI for cannabis use in individuals on medications for OUD.

The Interaction of Opiate Misuse and Marijuana Use on Behavioral Health Outcomes Using the Traumatic Brain Injury Model Systems Pain Collaborative Dataset

OBJECTIVE

To determine if the interaction of opiate misuse and marijuana use frequency is associated with behavioral health outcomes.

SETTING

Community.

PARTICIPANTS

Three thousand seven hundred fifty participants enrolled in the Traumatic Brain Injury Model Systems who completed the Pain Survey and had complete opioid use and marijuana use information.

DESIGN

Cross-sectional, secondary analysis from a multisite observational cohort.

MAIN OUTCOME MEASURES

Clinically significant behavioral health symptoms for posttraumatic stress disorder (PTSD), depression, anxiety, and sleep quality.

RESULTS

Three thousand five hundred thirty-five (94.3%) participants did not misuse opiates, 215 (5.7%) did misuse opiates (taking more opioid pain medication than prescribed and/or using nonprescription opioid pain medication); 2683 (70.5%) participants did not use marijuana, 353 (9.3%) occasionally used marijuana (less than once a week), and 714 (18.8%) regularly used marijuana (once a week or more frequently). There was a statistically significant relationship (P < .05) between the interaction of opiate misuse and marijuana use frequency and all behavioral health outcomes and several covariates (age, sex, cause of injury, severity of injury, and pain group category). Pairwise comparisons confirm that statistically significant associations on behavioral health outcomes are driven by endorsing opiate misuse and/or regular marijuana use, but occasional marijuana use was not associated.

CONCLUSIONS

Higher odds of clinically significant PTSD, depression, anxiety, and poor sleep quality are present in people with traumatic brain injury (TBI) who misuse opiates and/or who use marijuana regularly. In the absence of opiate misuse, regular marijuana use had higher odds of worse behavioral health outcomes than occasional and no use. The interaction of opiate misuse and regular marijuana use yielded the highest odds. Individuals with TBI should be informed of the relationship of substance use and behavioral health outcomes and that current chronic pain may mediate the association.

Cannabis use to manage opioid cravings among people who use unregulated opioids during a drug toxicity crisis

BACKGROUND

Accumulating evidence has indicated that cannabis substitution is often used as a harm reduction strategy among people who use unregulated opioids (PWUO) and people living with chronic pain. We sought to investigate the association between cannabis use to manage opioid cravings and self-reported changes in opioid use among structurally marginalized PWUO.

METHODS

The data were collected from a cross-sectional questionnaire administered to PWUO in Vancouver, Canada. Binary logistic regression was used to analyze the association between cannabis use to manage opioid cravings and self-reported changes in unregulated opioid use.

RESULTS

A total of 205 people who use cannabis and opioids were enrolled in the present study from December 2019 to November 2021. Cannabis use to manage opioid cravings was reported by 118 (57.6%) participants. In the multivariable analysis, cannabis use to manage opioid cravings (adjusted Odds Ratio [aOR] = 2.13, 95% confidence interval [CI]: 1.07, 4.27) was significantly associated with self-reported reductions in opioid use. In the sub-analyses of pain, cannabis use to manage opioid cravings was only associated with self-assessed reductions in opioid use among people living with moderate to severe pain (aOR = 4.44, 95% CI: 1.52, 12.97). In the sub-analyses of males and females, cannabis use to manage opioid cravings was only associated with self-assessed reductions in opioid use among females (aOR = 8.19, 95% CI: 1.20, 55.81).

CONCLUSIONS

These findings indicate that cannabis use to manage opioid cravings is a prevalent motivation for cannabis use among PWUO and is associated with self-assessed reductions in opioid use during periods of cannabis use. Increasing the accessibility of cannabis products for therapeutic use may be a useful supplementary strategy to mitigate exposure to unregulated opioids and associated harm during the ongoing drug toxicity crisis.

Delta-9-tetrahydrocannabinol modulates pain sensitivity among persons receiving opioid agonist therapy for opioid use disorder: A within-subject, randomized, placebo-controlled laboratory study

The opioid and cannabinoid receptor systems are inextricably linked-overlapping at the anatomical, functional and behavioural levels. Preclinical studies have reported that cannabinoid and opioid agonists produce synergistic antinociceptive effects. Still, there are no experimental data on the effects of cannabinoid agonists among humans who receive opioid agonist therapies for opioid use disorder (OUD). We conducted an experimental study to investigate the acute effects of the delta-9-tetrahydrocannabinol (THC) among persons receiving methadone therapy for OUD. Using a within-subject, crossover, human laboratory design, 25 persons on methadone therapy for OUD (24% women) were randomly assigned to receive single oral doses of THC (10 or 20 mg, administered as dronabinol) or placebo, during three separate 5-h test sessions. Measures of experimental and self-reported pain sensitivity, abuse potential, cognitive performance and physiological effects were collected. Mixed-effects models examined the main effects of THC dose and interactions between THC (10 and 20 mg) and methadone doses (low-dose methadone defined as <90 mg/day; high dose defined as >90 mg/day). Results demonstrated that, for self-reported rather than experimental pain sensitivity measures, 10 mg THC provided greater relief than 20 mg THC, with no substantial evidence of abuse potential, and inconsistent dose-dependent cognitive adverse effects. There was no indication of any interaction between THC and methadone doses. Collectively, these results provide valuable insights for future studies aiming to evaluate the risk-benefit profile of cannabinoids to relieve pain among individuals receiving opioid agonist therapy for OUD, a timely endeavour amidst the opioid crisis.

Sex differences in Cannabis use disorder and associated psychosocial problems among US adults, 2012-2013

While men show greater prevalence of cannabis use disorder (CUD) than women, whether cannabis use frequency drives this difference is unknown, and little is known about sex differences in problems associated with CUD. We therefore assessed the association of CUD with sex, adjusted for frequency of use, and compared the association of psychosocial and health-related problems with CUD between men and women. We included US adults age ≥ 18 who reported past-year cannabis use in the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III (n = 3701). Cannabis use frequency, DSM-5 CUD and problems (interpersonal, financial, legal, health-related) were assessed. Associations between psychosocial problems, sex and DSM-5 CUD were assessed using prevalence differences (PD) and 95% confidence intervals (CI) from logistic regression models, controlling for demographics and cannabis use frequency, and effect modification by sex was assessed. We found that the prevalence of CUD among men versus women was not significantly greater after adjusting for use frequency. Women had significantly higher prevalence of interpersonal, financial and health-related problems than men, adjusting for frequency of use. Women showed significantly greater association of CUD with interpersonal problems with a boss or co-workers (p < 0.05) and a neighbor, relative or friend (p < 0.05) compared to men. Lack of sex differences in CUD after adjusting for frequency of use suggests use frequency may be an important target of CUD prevention efforts. CUD showed stronger associations for interpersonal problems among women than men, suggesting the need for particular emphasis on treating interpersonal problems related to cannabis use among women.

Efficacy of Brief Interventions for Comorbid Substance Misuse in Patients on Opioid Agonist Treatment: A Systematic Review and Meta-analysis

BACKGROUND AND AIMS

Multiple substance use is a common but underrecognized problem in patients on opioid agonist treatment (OAT). Co-occurring substance misuse is associated with poor clinical and psychosocial outcomes. We aimed ( a ) to determine the effect of screening and brief intervention (SBI) for substance misuse in people on OAT and (b) to qualitatively summarize the implementation of SBI.

METHODS

We performed a systematic review of clinical trials on the efficacy of SBI for alcohol and drug misuse in participants on OAT. We searched 5 electronic databases and included published studies and unpublished trials. We measured the standardized mean difference in substance risk scores before and after intervention. We also estimated the standardized mean difference in alcohol consumption per day before and after intervention.

RESULTS

We included a total of 8 studies; 5 of these were included in the meta-analysis, and all were reviewed for narrative synthesis. We observed a significant change in the pre-post brief intervention substance risk scores with a medium effect size (Hedges g = 0.752, 95% confidence interval, 0.405-1.099). Sensitivity analyses with different pretest-posttest correlations did not change our result. Modest effects of SBI were found in reducing both alcohol and illicit drug risk scores, and among the population on methadone and buprenorphine treatment. We also observed a significant decrease in alcohol consumption per day 3 months after SBI. Studies showed a limited and incomplete screening for substance misuse and delivery of brief intervention in OAT settings.

CONCLUSIONS

Screening and brief intervention may be a potential treatment for co-occurring substance misuse among patients on OAT.

Frequencies of emergency department use and hospitalization comparing patients with different types of substance or polysubstance-related disorders

Background

This study measured emergency department (ED) use and hospitalization for medical reasons among patients with substance-related disorders (SRD), comparing four subgroups: cannabis-related disorders, drug-related disorders other than cannabis, alcohol-related disorders and polysubstance-related disorders, controlling for various clinical, sociodemographic and service use variables.

Methods

Clinical administrative data for a cohort of 22,484 patients registered in Quebec (Canada) addiction treatment centers in 2012-13 were extracted for the years 2009-10 to 2015-16. Using negative binomial models, risks of frequent ED use and hospitalization were calculated for a 12-month period (2015-16).

Results

Patients with polysubstance-related disorders used ED more frequently than other groups with SRD. They were hospitalized more frequently than patients with cannabis or other drug-related disorders, but less frequently than those with alcohol-related disorders. Patients with alcohol-related disorders used ED more frequently than those with cannabis-related disorders and underwent more hospitalizations than both patients with cannabis-related and other drug-related disorders. Co-occurring SRD-mental disorders or SRD-chronic physical illnesses, more years with SRD, being women, living in rural territories, more frequent consultations with usual general practitioner or outpatient psychiatrist, and receiving more interventions in community healthcare centers increased frequency of ED use and hospitalization, whereas both adverse outcomes decreased with high continuity of physician care. Behavioral addiction, age less than 45 years, living in more materially deprived areas, and receiving 1-3 interventions in addiction treatment centers increased risk of frequent ED use, whereas living in semi-urban areas decreased ED use. Patients 25-44 years old receiving 4+ interventions in addiction treatment centers experienced less frequent hospitalization.

Conclusion

Findings showed higher risk of ED use among patients with polysubstance-related disorders, and higher hospitalization risk among patients with alcohol-related disorders, compared with patients affected by cannabis and other drug-related disorders. However, other variables contributed substantially more to the frequency of ED use and hospitalization, particularly clinical variables regarding complexity and severity of health conditions, followed by service use variables. Another important finding was that high continuity of physician care helped decrease the use of acute care services. Strategies like integrated care and outreach interventions may enhance SRD services.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13011-021-00421-7.

Cannabis Use, Cannabis Use Disorder, and Comorbid Psychiatric Illness: A Narrative Review

BACKGROUND

The landscape of attitudes, legal status and patterns of use of cannabis is rapidly changing in the United States and elsewhere. Therefore, the primary aim of this narrative review is to provide a concise overview of the literature on the comorbidity of cannabis use and cannabis use disorder (CUD) with other substance use and psychiatric disorders, and to use this information to accurately guide future directions for the field.

METHODS

A literature review of PubMed was conducted for studies relating to cannabis use, CUD, and a co-occurring psychiatric disorder. To provide an overview of representative data, the literature review focused on national-level, population-based work from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) and National Survey on Drug Use and Health (NSDUH) surveys. Considering rapidly changing cannabis laws, recent (past five-year) studies were addressed.

RESULTS

A strong body of literature shows associations between cannabis use and CUD with other drug use, psychosis, mood disorders, anxiety disorders, and personality disorders. The strongest evidence of a potential causal relationship exists between cannabis use and psychotic disorders. While some evidence shows potential directionality between cannabis use and mood and anxiety disorders, results are inconsistent. Studies have established higher rates of CUD among those with personality disorders, but little about the specifics of this relationship is understood.

CONCLUSIONS

Although the general population in the United States increasingly perceives cannabis to be a harmless substance, empirical evidence shows that cannabis use is associated both with CUD and comorbid psychiatric illness. However, there is mixed evidence regarding the role of cannabis in the etiology, course, and prognosis of a co-occurring disorder across all categories of psychiatric disorders. Future research should expand on the existing body of literature with representative, longitudinal data, in order to better understand the acute and long-term effects of cannabis on comorbid psychiatric illness.

Impact of cannabis on non-medical opioid use and symptoms of posttraumatic stress disorder: a nationwide longitudinal VA study

BACKGROUND

Multiple states have authorized cannabis as an opioid substitution agent and as a treatment for posttraumatic stress disorder (PTSD).

OBJECTIVES

This study sought to investigate the relationship between cannabis use, non-medical opioid use, and PTSD symptoms among U.S. veterans.

METHODS

From 1992-2011, veterans admitted to specialized intensive PTSD treatment participated in a national evaluation with assessments at intake and four months after discharge. Participants with non-medical opioid use ≥ 7 days during the 30 days preceding admission were divided into two groups: those with cannabis use ≥ 7 days, and those without cannabis use. These two groups were compared on measures of substance use and PTSD symptoms at baseline and 4-months outpatient follow-up. We hypothesized that, at both assessments, the group with baseline cannabis use would show less non-medical opioid use and less severe PTSD symptoms.

RESULTS

Of 1,413 veterans with current non-medical opioid use, 438 (30.3%) also used cannabis, and 985 (69.7%) did not. At baseline, veterans with concurrent non-medical opioid and cannabis use had slightly fewer days of non-medical opioid use (p < .005; d = -0.16), greater use of other substances (p < .0001) and more PTSD symptoms (p = .003; d = 0.16), compared to veterans who used non-medical opioids but not cannabis. At follow-up, substance use or PTSD symptoms did not significantly differ.

CONCLUSION

Cannabis use was not associated with a substantial reduction of non-medical opioid use, or either improvement or worsening of PTSD symptoms in this population. Hence, these data do not encourage cannabis use to treat either non-medical opioid use or PTSD.