Site maintenance Wednesday, November 13th, 2024. Please note that access to some content and account information will be unavailable on this date.
Skip to main content
Full access
Editorials
Published Online: 1 January 2022

Intricacies of Researching Cannabis Use and Use Disorders Among Veterans in the United States

In their article in this issue, Browne et al. (1) present a dynamic approach to examining cannabis use and cannabis use disorder, based on DSM-5 criteria (2), among veteran populations, using data from the 2012–2013 National Epidemiologic Survey on Alcohol and Related Conditions–III (NESARC-III). The authors highlight the paucity of research assessing cannabis use and use disorder among veterans in the United States and the acute need for ongoing surveillance of cannabis use in this population, and their work calls attention to the importance of examining the intricacies of cannabis research among U.S. veterans.
The veterans in this study were those who were no longer on active duty, but had served on active duty in the U.S. Armed Forces, National Guard, or Military Reserves. Sociodemographic characteristics were recorded in the NESARC-III sample; weighting was used to provide nationally representative results. After weighting, the sample comprised low proportions of women, younger people (particularly the 18- to 29-year age range), individuals not identifying as White, rural residents, people with less than a high school education, individuals experiencing unemployment, and people in the lowest family income bracket ($0–$19,999). The Alcohol Use Disorder and Associated Disabilities Interview Schedule–5 (AUDADIS-5) was used to measure lifetime and past-12-month cannabis use. Use was categorized as nonmedical use alone (use without a prescription or to get high one or more times in the past 12 months), medical use alone, or both. Respondents who disclosed medical cannabis use alone were not asked questions related to cannabis use disorder, so no cannabis use disorder–related information on this small group could be provided. Extensive information is provided on the reliability and validity of DSM-5 diagnoses using the AUDADIS-5 (3), and the kappa values were within the norm for structured clinical interviews of this type. Previous use of DSM-IV to compare findings from the AUDADIS-ADR, the Composite International Diagnostic Interview, and the Schedules for Clinical Assessment in Neuropsychiatry determined that agreement between cannabis use disorder findings were less than for any other substance use disorder (4). However, this comparison was based on DSM-IV (4), not DSM-5 as used by Browne et al.
The Browne et al. study likely underestimated cannabis use and use disorder among U.S. veterans. The prevalence of past-12-month cannabis use was 7.3%, and the prevalence of past-12-month cannabis use disorder was 1.8%, as assessed by DSM-5 criteria. The authors point out that previous research in patients of the Veterans Health Administration revealed greater prevalence of use but lower prevalence of cannabis use disorder (57). However, in an earlier study, Hasin et al. found a higher prevalence of past-12-month cannabis use disorder among adults sampled in the 2012–2013 NESARC-III (8) than did Browne et al. in their veterans-only subsample. This highlights the importance of comparing prevalence estimates from subpopulations to those of a nationally representative sample, given that some may assume higher drug use among people after military service.
Additionally, Browne et al. observed a positive association between lifetime cannabis use disorder and answers that met the criteria for lifetime posttraumatic stress disorder (PTSD). Studies have considered rates of comorbidity of PTSD and cannabis use disorder among veterans (9, 10), and have also considered the use of cannabis to treat PTSD. For instance, a majority (58.5%) of veterans in one health group sample self-reported cannabis use to treat PTSD (11). A study by Petersen et al. (12) found no positive effect of cannabis on PTSD; only antidepressants reduced PTSD symptoms in that study, in a largely white and male sample. A randomized clinical trial also did not reveal significant differences in improving PTSD symptoms when comparing several types of smoked cannabis to placebo (13). A small qualitative study among veterans with PTSD found some positive but also some negative consequences associated with medical cannabis use (14). Additional research regarding the effectiveness and efficiency of using cannabis to treat PTSD symptoms in veterans may be warranted.
We simply don’t know if those using cannabis only medically also experienced the consequences measured as cannabis use disorder, because of an enduring quandary in the nosology of cannabis use disorder. The AUDADIS and some other measures characterize use disorder only when the person endorses nonmedical use. But differentiating medical from nonmedical cannabis use, even conceptually, remains fraught with challenges. Some people who have a medical prescription for cannabis may also use cannabis for its mood-altering properties; thus, they may endorse using to get high and also using for pain relief. Some individuals may want to receive medical cannabis but be unable or unwilling to obtain a prescription because of a lack of health insurance or financial resources, limited geographical access to a prescribing health professional for medical marijuana, or concerns about the potential stigmatization of asking for, receiving, or using medical cannabis. Others may have a health provider endorse their medical use but may similarly experience barriers to purchasing through an authorized dispensary. As previously noted, in the Browne et al. study, nonmedical cannabis use was classified as endorsing using cannabis without a prescription or a medical referral or using it in a manner other than as prescribed. Since the types of qualifying health conditions for medical marijuana vary by state, an individual may qualify for medical use in one state but not in another, so cannabis could be used for a health-related concern that currently does not qualify for medical use in a particular state. Thus, accurate measurement of whether cannabis was used medically and/or nonmedically is a particularly complex issue, and when AUDADIS-5 questions that measure problematic use and negative consequences of use are not asked of individuals who endorsed medical use alone, this likely leads to underestimation of the prevalence of cannabis use disorder.
Another particularly notable finding from the Browne et al. study was that veterans who endorsed past 12-month cannabis use also had increased odds of a past-12-month opioid use disorder and increased odds of using cannabis. The authors point to another study that suggests a positive association between using cannabis in 2001–2002 and incidence of an opioid use disorder in 2004–2005 among U.S. adults with moderate to severe pain (1, 15). However, other research has found that cannabis use may help manage symptoms related to opioid use, such as withdrawal (1618). Findings from Browne et al. also revealed that prevalence of past-12-month nonmedical cannabis use and, more concerningly, prevalence of cannabis use disorder are higher in U.S. states with medical marijuana laws compared with those that have not legalized medical marijuana. Given that U.S. states are increasingly legalizing not only medical but also recreational marijuana use, the findings of Browne et al. contribute to a growing literature supporting the need for further research on the implications of changing legalization and public policy regarding cannabis use for veterans. While Veterans Administration health professionals are currently prohibited from prescribing medical marijuana (19), it is critical that veterans using cannabis receive medical guidance regarding the risks and benefits of cannabis use, regular screenings for cannabis use disorder, and timely and appropriate access to resources and support services related to cannabis use, especially if they experience adverse symptoms associated with use.

Footnotes

Ms. Hoeflich is supported by the UF Substance Abuse Training Center in Public Health from NIDA award number T32DA035167 (principal investigator, Linda Cottler, Ph.D.).
The content of this editorial is solely the responsibility of the authors and does not necessarily represent the official views of NIH.

References

1.
Browne KC, Stohl M, Bohnert KM, et al: Prevalence and correlates of cannabis use and cannabis use disorder among US veterans: results from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III). Am J Psychiatry 2022; 179:26–35
2.
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Washington, DC, American Psychiatric Association, 2013
3.
Grant BF, Goldstein RB, Smith SM, et al: The Alcohol Use Disorder and Associated Disabilities Interview Schedule-5 (AUDADIS-5): reliability of substance use and psychiatric disorder modules in a general population sample. Drug Alcohol Depend 2015; 148:27–33
4.
Cottler LB, Grant BF, Blaine J, et al: Concordance of DSM-IV alcohol and drug use disorder criteria and diagnoses as measured by AUDADIS-ADR, CIDI, and SCAN. Drug Alcohol Depend 1997; 47:195–205
5.
Bonn-Miller MO, Harris AHS, Trafton JA: Prevalence of cannabis use disorder diagnoses among veterans in 2002, 2008, and 2009. Psychol Serv 2012; 9:404–416
6.
Gentes EL, Schry AR, Hicks TA, et al: Prevalence and correlates of cannabis use in an outpatient VA posttraumatic stress disorder clinic. Psychol Addict Behav 2016; 30:415–421
7.
Goldman M, Suh JJ, Lynch KG, et al: Identifying risk factors for marijuana use among Veterans Affairs patients. J Addict Med 2010; 4:47–51
8.
Hasin DS, Kerridge BT, Saha TD, et al: Prevalence and correlates of DSM-5 Cannabis use disorder, 2012–2013: findings from the National Epidemiologic Survey on Alcohol and Related Conditions–III. Am J Psychiatry 2016; 173:588–599
9.
Bryan JL, Hogan J, Lindsay JA, et al: Cannabis use disorder and post-traumatic stress disorder: the prevalence of comorbidity in veterans of recent conflicts. J Subst Abuse Treat 2021; 122:108254
10.
Hill ML, Nichter BM, Norman SB, et al: Burden of cannabis use and disorder in the US veteran population: psychiatric comorbidity, suicidality, and service utilization. J Affect Disord 2021; 278:528–535
11.
Loflin MJE, Babson K, Sottile J, et al: A cross-sectional examination of choice and behavior of veterans with access to free medicinal cannabis. Am J Drug Alcohol Abuse 2019; 45:506–513
12.
Petersen M, Koller K, Straley C, et al: Effect of cannabis use on PTSD treatment outcomes in veterans. Ment Health Clin 2021; 11:238–242
13.
Bonn-Miller MO, Sisley S, Riggs P, et al: The short-term impact of 3 smoked cannabis preparations versus placebo on PTSD symptoms: a randomized cross-over clinical trial. PLoS One 2021; 16:e0246990
14.
Krediet E, Janssen DG, Heerdink ER, et al: Experiences with medical cannabis in the treatment of veterans with PTSD: results from a focus group discussion. Eur Neuropsychopharmacol 2020; 36:244–254
15.
Olfson M, Wall MM, Liu S-M, et al: Cannabis use and risk of prescription opioid use disorder in the United States. Am J Psychiatry 2018; 175:47–53
16.
Clem SN, Bigand TL, Wilson M: Cannabis use motivations among adults prescribed opioids for pain versus opioid addiction. Pain Manag Nurs 2020; 21:43–47
17.
Scavone JL, Sterling RC, Weinstein SP, et al: Impact of cannabis use during stabilization on methadone maintenance treatment. Am J Addict 2013; 22:344–351
18.
Bergeria CL, Huhn AS, Dunn KE: The impact of naturalistic cannabis use on self-reported opioid withdrawal. J Subst Abuse Treat 2020; 113:108005
19.
Office of Patient Care Services, Veterans Health Administration, US Department of Veterans Affairs: VA and Marijuana: What Veterans Need to Know. https://www.publichealth.va.gov/marijuana.asp

Information & Authors

Information

Published In

Go to American Journal of Psychiatry
Go to American Journal of Psychiatry
American Journal of Psychiatry
Pages: 5 - 7
PubMed: 34974758

History

Accepted: 12 November 2021
Published online: 1 January 2022
Published in print: January 2022

Keywords

  1. Substance-Related and Addictive Disorders
  2. Cannabis
  3. Substance-Related and Addictive Disorders

Authors

Details

Catherine W. Striley, Ph.D., M.S.W. [email protected]
Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, Gainesville
Carolin C. Hoeflich, M.S.
Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, Gainesville

Notes

Send correspondence to Dr. Striley ([email protected]).

Competing Interests

The authors report no financial relationships with commercial interests.

Metrics & Citations

Metrics

Citations

Export Citations

If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download.

For more information or tips please see 'Downloading to a citation manager' in the Help menu.

Format
Citation style
Style
Copy to clipboard

View Options

View options

PDF/EPUB

View PDF/EPUB

Get Access

Login options

Already a subscriber? Access your subscription through your login credentials or your institution for full access to this article.

Personal login Institutional Login Open Athens login

Not a subscriber?

Subscribe Now / Learn More

PsychiatryOnline subscription options offer access to the DSM-5-TR® library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development.

Need more help? PsychiatryOnline Customer Service may be reached by emailing [email protected] or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.).

Media

Figures

Other

Tables

Share

Share

Share article link

Share