Importance:Little is known about patterns (forms, frequency, and reasons) and factors associated with cannabis use in older veterans (aged ≥65 years). Objective:To examine factors associated with past 30-day cannabis use and cannabis use disorder (CUD) in older veterans. Design, Setting, and Participants:In this cross-sectional study, community-dwelling adults aged 65 to 84 years who used Veterans Health Administration care were interviewed between February 5, 2020, and August 29, 2023. Exposure:Sociodemographic, behavioral, and health-related characteristics. Main Outcomes and Measures:Past 30-day cannabis use (smoking, vaping, dabbing, or edibles) and any CUD (≥2 criteria based on Diagnostic and Statistical Manual of Mental Disorders [Fifth Edition]) were assessed using weighted multivariable logistic regressions. Results:Of the 4503 participants (weighted mean age, 73.3 years [95% CI, 73.0-73.5 years]; 85.4% [95% CI, 83.6%-87.2%] men), 58.2% (95% CI, 55.3%-61.0%) had ever used cannabis, 28.9% (95% CI, 26.0%-31.8%) of whom reported using cannabis for medical reasons, most commonly for pain (56.4%; 95% CI, 50.9%-61.9%), mood or mental health (18.4%; 95% CI, 14.7%-22.1%), and sleep (16.0%; 95% CI, 11.9%-20.0%). More than 1 in 10 reported past 30-day cannabis use (10.3%; 95% CI, 8.9%-11.7%), with 52.4% (95% CI, 45.4%-59.4%) of these using cannabis for 20 days or more; smoking (72.4%; 95% CI, 65.4%-79.3%) and edibles (36.9%; 95% CI, 29.8%-43.9%) were the most common forms of use. Characteristics associated with past 30-day use included younger age (65-75 years), economic hardship, tobacco and illicit drug use, and residing in a state with recreationally legal cannabis. Among those with past 30-day cannabis use, 36.3% (95% CI, 30.1%-42.6%) screened positive for CUD, with higher odds among younger respondents, those reporting anxiety, those with 1 or more deficits in activities of daily living, those with illicit drug use, those with frequent cannabis use, and those using cannabis recreationally. Past 30-day inhaled cannabis use, compared with edibles only, was associated with increased odds of any CUD (adjusted odds ratio, 3.56; 95% CI, 1.12-11.26). Conclusions and Relevance:In this cross-sectional study of cannabis use in older veterans, use was common, and more than one-third who used in the past 30 days had any CUD. The prevalence of past 30-day cannabis use was close to tobacco use prevalence, and risk factors for cannabis use were similar to those observed in other populations. Frequent and inhaled cannabis use was associated with higher odds of any CUD. Routine health screening for cannabis use in Veterans Health Administration clinical settings is necessary to identify older adults with cannabis use.

Background The Veterans Health Administration tracks urine drug tests (UDTs) among patients on long-term opioid therapy (LTOT) and recommends discussing the health effects of cannabis use. Objective To determine the occurrence of cannabis-related discussions between providers and patients on LTOT during six months following UDT positive for cannabis, and examine factors associated with documenting cannabis use. Design We identified patients prescribed LTOT with a UDT positive for cannabis in 2019. We developed a text-processing tool to extract discussions around cannabis use from their charts. Subjects Twelve thousand seventy patients were included. Chart review was conducted on a random sample of 1,946 patients. Main measures The presence of a cannabis term in the chart suggesting documented cannabis use or cannabis-related discussions. Content of those discussions was extracted in a subset of patients. Logistic regression was used to examine the association between patient factors, including state of residence legal status, with documentation of cannabis use. Key Results Among the 12,070 patients, 65.8% ( N = 7,948) had a cannabis term, whereas 34.1% ( N = 4,122) of patients lacked a cannabis term, suggesting that no documentation of cannabis use or discussion between provider and patient took place. Among the subset of patients who had a discussion documented, 47% related to cannabis use for medical reasons, 35% related to a discussion of VA policy or legal issues, and 17% related to a discussion specific to medical risks or harm reduction strategies. In adjusted analyses, residents of states with legalized recreational cannabis were less likely to have any cannabis-related discussion compared to patients in non-legal states [OR 0.73, 95% CI 0.64–0.82]. Conclusions One-third of LTOT patients did not have documentation of cannabis use in the chart in the 6 months following a positive UDT for cannabis. Discussions related to the medical risks of cannabis use or harm reduction strategies were uncommon.

Abstract Background Cannabis is marketed as a treatment for pain. There is limited data on the prevalence of cannabis use and its correlates among Veterans prescribed opioids. Objective To examine the prevalence and correlates of cannabis use among Veterans prescribed opioids. Design Cross-sectional study. Participants Veterans with a urine drug test (UDT) from Primary Care 2014–2018, in 50 states, Washington, D.C., and Puerto Rico. A total of 1,182,779 patients were identified with an opioid prescription within 90 days prior to UDT. Main measures Annual prevalence of cannabis positive UDT by state. We used multivariable logistic regression to assess associations of demographic factors, mental health conditions, substance use disorders, and pain diagnoses with cannabis positive UDT. Results Annual prevalence of cannabis positive UDT ranged from 8.5% to 9.7% during the study period, and in 2018 was 18.15% in Washington, D.C. and 10 states with legalized medical and recreational cannabis, 6.1% in Puerto Rico and 25 states with legalized medical cannabis, and 4.5% in non-legal states. Younger age, male sex, being unmarried, and marginal housing were associated with use (p < 0.001). Post-traumatic stress disorder (adjusted odds ratio [AOR] 1.17; 95% confidence interval [CI] 1.13–1.22, p < 0.001), opioid use disorder (AOR 1.14; CI 1.07–1.22, p < 0.001), alcohol use disorder or positive AUDIT-C (AOR 1.34; 95% CI 1.28–1.39, p < 0.001), smoking (AOR 2.58; 95% CI 2.49–2.66, p < 0.001), and other drug use disorders (AOR 1.15; 95% CI 1.03–1.29, p = 0.02) were associated with cannabis use. Positive UDT for amphetamines AOR 1.41; 95% CI 1.26–1.58, p < 0.001), benzodiazepines (AOR 1.41; 95% CI 1.31–1.51, p < 0.001) and cocaine (AOR 2.04; 95% CI 1.75–2.36, p < 0.001) were associated with cannabis positive UDT. Conclusions Cannabis use among Veterans prescribed opioids varied by state and by legalization status. Veterans with PTSD and substance use disorders were more likely to have cannabis positive UDT. Opioid-prescribed Veterans using cannabis may benefit from screening for these conditions, referral to treatment, and attention to opioid safety.

IMPORTANCE Cannabis has been proposed as a therapeutic with potential opioid-sparing properties in chronic pain, and its use could theoretically be associated with decreased amounts of opioids used and decreased risk of mortality among individuals prescribed opioids. OBJECTIVE To examine the risks associated with cannabis use among adults prescribed opioid analgesic medications. DESIGN, SETTING, AND PARTICIPANTS This cohort study was conducted among individuals aged 18 years and older who had urine drug screening in 2014 to 2019 and received any prescription opioid in the prior 90 days or long-term opioid therapy (LTOT), defined as more than 84 days of the prior 90 days, through the Veterans Affairs health system. Data were analyzed from November 2020 through March 2022. EXPOSURES Biologically verified cannabis use from a urine drug screen. MAIN OUTCOMES AND MEASURES The main outcomes were 90-day and 180-day all-cause mortality. A composite outcome of all-cause emergency department (ED) visits, all-cause hospitalization, or all-cause mortality was a secondary outcome. Weights based on the propensity score were used to reduce confounding, and hazard ratios [HRs] were estimated using Cox proportional hazards regression models. Analyses were conducted among the overall sample of patients who received any prescription opioid in the prior 90 days and were repeated among those who received LTOT. Analyses were repeated among adults aged 65 years and older. RESULTS Among 297 620 adults treated with opioids, 30 514 individuals used cannabis (mean [SE] age, 57.8 [10.5] years; 28 784 [94.3%] men) and 267 106 adults did not (mean [SE] age, 62.3 [12.3] years; P <.001; 247 684 [92.7%] men; P <.001). Among all patients, cannabis use was not associated with increased all-cause mortality at 90 days (HR, 1.07; 95% CI, 0.92-1.22) or 180 days (HR, 1.00; 95% CI, 0.90-1.10) butwas associated with an increased hazard of the composite outcome at 90 days (HR, 1.05; 95% CI, 1.01-1.07) and 180 days (HR, 1.04; 95% CI, 1.01-1.06). Among 181 096 adults receiving LTOT, cannabis use was not associated with increased risk of all-cause mortality at 90 or 180 days but was associated with an increased hazard of the composite outcome at 90 days (HR, 1.05; 95% CI, 1.02-1.09) and 180 days (HR, 1.05; 95% CI, 1.02-1.09). Among 77 791 adults aged 65 years and older receiving LTOT, cannabis usewas associated with increased 90-day mortality (HR, 1.55; 95% CI, 1.17-2.04). CONCLUSIONS AND RELEVANCE This study found that cannabis use among adults receiving opioid analgesic medications was not associated with any change in mortality risk but was associated with a small increased risk of adverse outcomes and that short-term risks were higher among older adults receiving LTOT.

BACKGROUND:Hospitalizations related to the consequences of opioid use are rising. National guidelines directing in-hospital opioid use disorder (OUD) management do not exist. OUD treatment guidelines intended for other treatment settings could inform in-hospital OUD management.OBJECTIVE:Evaluate the quality and content of existing guidelines for OUD treatment and management.DATA SOURCES:OVID MEDLINE, PubMed, Ovid PsychINFO, EBSCOhost CINHAL, ERCI Guidelines Trust, websites of relevant societies and advocacy organizations, and selected international search engines.STUDY SELECTION:Guidelines published between January 2010 to June 2020 addressing OUD treatment, opioid withdrawal management, opioid overdose prevention, and care transitions among adults.DATA EXTRACTION:We assessed quality using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument.DATA SYNTHESIS:Nineteen guidelines met the selection criteria. Most recommendations were based on observational studies or expert consensus. Guidelines recommended the use of nonstigmatizing language among patients with OUD; to assess patients with unhealthy opioid use for OUD using the Diagnostic Statistical Manual of Diseases-5th Edition criteria; use of methadone or buprenorphine to treat OUD and opioid withdrawal; use of multimodal, nonopioid therapy, and when needed, short-acting opioid analgesics in addition to buprenorphine or methadone, for acute pain management; ensuring linkage to ongoing methadone or buprenorphine treatment; referring patients to psychosocial treatment; and ensuring access to naloxone for opioid overdose reversal.CONCLUSIONS:Included guidelines were informed by studies with various levels of rigor and quality. Future research should systematically study buprenorphine and methadone initiation and titration among people using fentanyl and people with pain, especially during hospitalization.

Background: Co-prescribing opioids and benzodiazepines increases overdose risk. A paucity of literature exists evaluating strategies to improve safety of co-prescribing. This study evaluated an electronic intervention to improve safety for patients co-prescribed chronic opioids for pain and benzodiazepines at 3 and 6 months. Methods: A prospective cohort study was conducted from December 2015 through May 2016 at San Francisco Veterans Affairs Health Care System. A clinical dashboard identified 145 eligible patients prescribed chronic opioids and benzodiazepines. Individualized taper and safety recommendations were communicated to prescribers via electronic medical record progress note and encrypted e-mail at baseline. Primary outcome was number of patients co-prescribed chronic opioids and benzodiazepines. Secondary outcomes included daily dose of opioids and benzodiazepines and number prescribed ≥100 mg morphine equivalent daily dose. Safety outcomes included number with opioid overdose education and naloxone distribution, annual urine drug screening, annual prescription drug monitoring program review, and signed opioid informed consent. Linear mixed models and generalized estimating equations were used to examine within-group change in outcomes between baseline and 3 and 6 months. Results: Among the 145 patients, mean (standard deviation) age was 62 (11) years and 91.7% (133/145) were male. Number co-prescribed significantly decreased from 145/145 (100%) at baseline to 93/139 (67%) at 6-month follow-up (odds ratio [OR] = 0.53, 95% confidence interval [CI]: 0.34–0.81, P = .003). Mean opioid and benzodiazepine doses significantly decreased from 84.61 to 65.63 mg (95% CI: 8.32–27.86, P < .001) and from 16.10 to 13.45 mg (95% CI: 1.6–3.9, P < .001), respectively, from baseline to 6-month follow-up. Patients prescribed ≥100 mg morphine equivalent daily dose significantly decreased from 39/145 (26.8%) at baseline to 26/139 (18.7%) at end of study (OR = 0.59, 95% CI: 0.44–0.78, P < .001), and patients with opioid overdose education and naloxone distribution significantly increased from 3/145 (2.1%) at baseline to 46/139 (33.1%; OR = 23.4, 95% CI: 7.61–71.99, P < .001) by the end of study. Number of patients with annual urine drug screening tended to increase from 123/145 (84.8%) at baseline to 132/145 (91.4%) by the end of study (OR = 1.89, 95% CI: 0.95–3.76, P = .07), and there were no significant changes across time in numbers of patients with annual prescription drug monitoring program review or signed opioid informed consent. Conclusions: Electronic interventions may provide an effective strategy to improve safety for patients co-prescribed chronic opioids for pain and benzodiazepines.

Article AbstractBecause this piece does not have an abstract, we have provided for your benefit the first 3 sentences of the full text.Cannabis use is increasingly visible as policy shifts toward legalization in many states, and the potential impact of cannabis use on patients is an important issue for mental health providers to understand. As of early 2018, 9 US states have laws allowing recreational cannabis use, and fewer adults now perceive cannabis as risky than ever before. Yet, the degree to which cannabis use can be harmful is often unclear to clinicians.

Objective:Cannabis is the most commonly used illicit substance in the United States and is increasingly being legalized throughout the United States. Many believe that cannabis is relatively harmless, and some believe that cannabis is not addictive. We wondered what the rates of cannabis abuse and dependence might be among adolescents referred for substance use evaluations and also about the incidence of co-occurring psychiatric illnesses and substance use disorders among those individuals. Methods:Herein, we analyze intake data from 483 adolescents referred for evaluation at an adolescent substance abuse clinic, with information gleaned from the adolescents and their parents or caregivers. Results:Forty-seven percent of our sample met the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision) criteria for cannabis dependence and another 32% for cannabis abuse. Among adolescents with cannabis use disorders, the co-occurrence of alcohol and opioid abuse or dependence was high. These individuals also suffered from significant psychiatric comorbidities otherwise. Conclusions:Our results show that cannabis use carries the risk of dependence and also carries with it significant risk of comorbidities, both with respect to other substance use disorders and other psychiatric illness. Given the growing body of research linking cannabis use with addiction and other psychiatric illness, public health efforts ought to center on the potential dangers of cannabis use.