A cross-sectional examination of choice and behavior of veterans with access to free medicinal cannabis
Mallory J E Loflin, Kimberly Babson, James Sottile, Sonya B Norman, Staci Gruber, and Marcel O Bonn-Miller
The American Journal of Drug and Alcohol Abuse, 2019, VOL. 45, NO. 5, 506–513.
Doi : 10.1080/00952990.2019.1604722
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.
KEYWORDS : Cannabis; marijuana; veterans; medicinal cannabis; therapeutics; substitution
There is a growing public demand to increase access to medicinal cannabis for US military veterans. Meanwhile, there is limited scientific evidence specifying which of the multitude of cannabinoid products offer the greatest therapeutic benefit and/or lowest risk of harm. Self-report studies that attempt to capture which products cannabis users choose and for what purpose are inherently biased by differences in ease of access to different products and preparations across US states and counties. Understandin how reducing barriers to access might impact cannabinoid choice and behavior among military veterans is of paramount importance.
Emerging evidence suggests the therapeutic potential of cannabinoids for a range of conditions relevant to military veteran health (1), including chronic pain (2–4), traumatic brain injury (TBI) (5–8), substance use disorder (SUD) (9– 15), and posttraumatic stress disorder (PTSD) (16–22).
Likely stemming from its actual or perceived therapeutic efficacy for many physical and psychological symptoms, many individuals are using cannabis as a substitute for more traditional pharmaceuticals (23), as well as licit and illicit substances (24). Epidemiological findings highlight this trend, documenting decreased opioid use within states that have transitioned to allow access tomedicinal cannabis (25,26). Likewise, preliminary analysis from one longitudinal study found reductions in the use of prescription medications including opiates, antidepressants, mood stabilizers, and benzodiazepines three months after initiation of medical cannabis (27).
Cannabis use, however, is also associated with a variety of negative effects, including risk of cannabis use disorder CUD (28). Relevant to veterans, CUD diagnoses have increased substantially in the past decade (29), specifically among veterans with PTSD (30). The contrast between therapeutic potential and increased problems may be attributable to the fact that “cannabis” represents a heterogeneous drug containing hundreds of cannabinoids, flavonoids, and terpenoids (31), which are associated with differential risk and potential therapeutic utility. For example, cannabis with higher delta 9-tetrahydro-cannabinol (THC) relative to cannabidiol (CBD) can be intoxicating and increase the risk of CUD (32), while cannabis with higher CBD relative to THC appears to have fewer of these properties (12,13). Preliminary evidence suggests that THC may be helpful for some physical conditions, such as neuropathic pain and spasticity due to multiple sclerosis (2), but may exacerbate mental health symptoms, such as PTSD (33) and depression (34). In contrast, CBD could be helpful for anxiety-related symptoms (35), such as PTSD (36), social anxiety (37), and insomnia (38).
Likewise, route of administration could impact both therapeutic potential and risk of problematic use. Bioavailability is directly impacted by whether cannabis products are smoked/vaporized, swallowed, absorbed sublingually, or administered topically (39–41), onset and duration of effects (42,43), and subjective experience of effects (43,44). Likewise, delivery of cannabis products that contain higher concentrations of THC is associated with greater risk of negative side effects (45,46), tolerance and withdrawal (47,48).
In this complex cannabis landscape, patient guidance and oversight is desperately needed, yet seriously lacking. Owing to the designation of cannabis as a schedule I controlled substance, health-care providers do not have sufficient evidence from well-controlled studies to make recommendations to patients on choice of product, best method of administration, or cannabinoid profile. Moreover, most health-care providers, including those working through the Veteran Affairs (VA) Healthcare System, are prohibited from offering specific advice on choosing cannabinoid-based products to their patients. Veterans who choose to self-medicate with cannabis must “go it on their own” in choosing cannabinoid preparations. Moreover, the cost of cannabis must be entirely shouldered by the consumer, as no insurance reimbursement is available. This creates substantial barriers for most veterans in accessing cannabis to self-treat symptoms.
To circumvent at least some of these barriers, veteran-focused cannabis collectives have begun to
emerge across the US, offering free cannabis products to veterans with state-approved cannabis cards. While a number of studies have documented characteristics of veteran cannabis users (49–52), these investigations have failed to address cannabis heterogeneity or the selection bias inherent in an environment with so many barriers to access. Findings may not generalize to the broader population of veterans who would initiate use if legal and financial barriers to access were reduced. The current study aimed to address some of these existing limitations by collecting data on cannabis preparation and administration preferences and potential substitution behavior in a sample of veterans with limited barriers to cannabis access.