State Cannabis Legalization and Cannabis Use Disorder in the US Veterans Health Administration, 2005 to 2019

Abstract

ImportanceCannabis use disorder (CUD) is increasing among US adults. Few national studies have addressed the role of medical cannabis laws (MCLs) and recreational cannabis laws (RCLs) in these increases, particularly in patient populations with high rates of CUD risk factors.ObjectiveTo quantify the role of MCL and RCL enactment in the increases in diagnosed CUD prevalence among Veterans Health Administration (VHA) patients from 2005 to 2019.Design, Setting, and ParticipantsStaggered-adoption difference-in-difference analyses were used to estimate the role of MCL and RCL in the increases in prevalence of CUD diagnoses, fitting a linear binomial regression model with fixed effects for state, categorical year, time-varying cannabis law status, state-level sociodemographic covariates, and patient age group, sex, and race and ethnicity. Patients aged 18 to 75 years with 1 or more VHA primary care, emergency department, or mental health visit and no hospice/palliative care within a given calendar year were included. Time-varying yearly state control covariates were state/year rates from American Community Survey data: percentage male, Black, Hispanic, White, 18 years or older, unemployed, income below poverty threshold, and yearly median household income. Analysis took place between February to December 2022.Main Outcomes and MeasuresAs preplanned, International Classification of Diseases, Clinical Modification, ninth and tenth revisions, CUD diagnoses from electronic health records were analyzed.ResultsThe number of individuals analyzed ranged from 3 234 382 in 2005 to 4 579 994 in 2019. Patients were largely male (94.1% in 2005 and 89.0% in 2019) and White (75.0% in 2005 and 66.6% in 2019), with a mean (SD) age of 57.0 [14.4] years. From 2005 to 2019, adjusted CUD prevalences increased from 1.38% to 2.25% in states with no cannabis laws (no CLs), 1.38% to 2.54% in MCL-only enacting states, and 1.39% to 2.56% in RCL-enacting states. Difference-in-difference results indicated that MCL-only enactment was associated with a 0.05% (0.05-0.06) absolute increase in CUD prevalence, ie, that 4.7% of the total increase in CUD prevalence in MCL-only enacting states could be attributed to MCLs, while RCL enactment was associated with a 1.12% (95% CI, 0.10-0.13) absolute increase in CUD prevalence, ie, that 9.8% of the total increase in CUD prevalence in RCL-enacting states could be attributed to RCLs. The role of RCL in the increases in CUD prevalence was greatest in patients aged 65 to 75 years, with an absolute increase of 0.15% (95% CI, 0.13-0.17) in CUD prevalence associated with RCLs, ie, 18.6% of the total increase in CUD prevalence in that age group.Conclusions and RelevanceIn this study of VHA patients, MCL and RCL enactment played a significant role in the overall increases in CUD prevalence, particularly in older patients. However, consistent with general population studies, effect sizes were relatively small, suggesting that cumulatively, laws affected cannabis attitudes diffusely across the country or that other factors played a larger role in the overall increases in adult CUD. Results underscore the need to screen for cannabis use and CUD and to treat CUD when it is present.

Association of Cannabis Legalization with Cannabis Positive Drug Screening in US Veterans

“…Previous national studies of MCL and RCL found post-enactment increases in the prevalence of self-reported use 2,9,10 and also in clinical diagnosis for cannabis use disorder (CUD) diagnoses in VHA patients, diagnoses that cannot be made without self-reported cannabis use. 8 Cannabis legalization could reduce concerns about disclosing cannabis use in surveys and clinical settings, potentially leading to artifactual findings on prevalence increases and MCL and RCL effects. An earlier VHA study showed increases in CUD diagnoses associated with MCL and RCL enactment from 2005 to 2019 among the overall VHA patient population 8 .…”

“…8 Cannabis legalization could reduce concerns about disclosing cannabis use in surveys and clinical settings, potentially leading to artifactual findings on prevalence increases and MCL and RCL effects. An earlier VHA study showed increases in CUD diagnoses associated with MCL and RCL enactment from 2005 to 2019 among the overall VHA patient population 8 . Since our UDS data do not rely on self-report or clinical attention to cannabis use disorder symptoms, the present study provides an important new source of data to understand the effects of MCL and RCL policies.…”

Cannabis and Cannabinoids for Pain and Posttraumatic Stress Disorder in Military Personnel and Veterans

“…Cannabis is now legal for medical use in at least 37 states and the District of Columbia (DC) and for recreational use in 21 states and DC. 1 With the gradual expansion of legal access to cannabis over the past 2 decades, the prevalence of cannabis use has increased in both the general population and veterans. 1 Although the reported use of cannabis within the past year among US military personnel remains low at less than 1%, 2 this low rate is likely attributable to regulations that prohibit its use, with severe penalties (eg, administrative separation and potentially other-than-honorable discharge with reduced benefits) for military personnel.…”

“…1 With the gradual expansion of legal access to cannabis over the past 2 decades, the prevalence of cannabis use has increased in both the general population and veterans. 1 Although the reported use of cannabis within the past year among US military personnel remains low at less than 1%, 2 this low rate is likely attributable to regulations that prohibit its use, with severe penalties (eg, administrative separation and potentially other-than-honorable discharge with reduced benefits) for military personnel.While the use of nonprescribed cannabis products is uncommon and illegal in the military, 3 cannabinoids are approved by the US Food and Drug Administration and can be legally prescribed to military personnel and veterans in clinical settings. Dronabinol, in particular, is occasionally prescribed to military personnel off-label to treat pain or symptoms of posttraumatic stress disorder (PTSD).…”

“…Cannabis is now legal for medical use in at least 37 states and the District of Columbia (DC) and for recreational use in 21 states and DC . With the gradual expansion of legal access to cannabis over the past 2 decades, the prevalence of cannabis use has increased in both the general population and veterans .…”