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BackgroundEvidence on the cardiovascular health effects of cannabis use is limited. We designed a prospective cohort study of older Veterans (66 to 68 years) with coronary artery disease (CAD) to understand the cardiovascular consequences of cannabis use. We describe the cohort construction, baseline characteristics, and health behaviors that were associated with smoking cannabis.ObjectiveTo understand the cardiovascular consequences of cannabis use.DesignWe designed a prospective cohort study of older Veterans (66 to 68 years) with CAD.ParticipantsA total of 1,015 current cannabis smokers and 3,270 non-cannabis smokers with CAD.Main measuresUsing logistic regression, we examined the association of baseline variables with smoking cannabis in the past 30 days.ResultsThe current cannabis smokers and non-current smokers were predominantly male (97.2% vs 97.1%, p=0.96). Characteristics associated with recent cannabis use in multivariable analyses included lack of a high school education (odds ratio [OR] 2.15, 95% confidence interval [CI]: 1.10 to 4.19), financial difficulty (OR 1.47, 95% CI: 1.02 to 2.11), tobacco use (OR 3.02, 95% CI: 1.66 to 5.48), current drug use (OR 2.82, 95% CI: 1.06 to 7.46), and prior drug use (OR 2.84, 95% CI: 2.11 to 3.82). In contrast, compared to individuals with 0 to 1 comorbid conditions, those with 5 chronic conditions or more (OR 0.43, 95% CI: 0.27 to 0.70) were less likely to smoke cannabis.ConclusionsIn this older high-risk cohort, smoking cannabis was associated with higher social and behavioral risk, but with fewer chronic health conditions.

ObjectiveIn the United States, adult cannabis use has increased over time, but less information is available on time trends in cannabis use disorder. The authors used Veterans Health Administration (VHA) data to examine change over time in cannabis use disorder diagnoses among veterans, an important population subgroup, and whether such trends differ by age group (

BackgroundSubstance use disorders (SUD) elevate the risk for COVID-19 hospitalization, but studies are inconsistent on the relationship of SUD to COVID-19 mortality.MethodsVeterans Health Administration (VHA) patients treated in 2019 and evaluated in 2020 for COVID-19 (n=5,556,315), of whom 62,303 (1.1%) tested positive for COVID-19 (COVID-19+). Outcomes were COVID-19+ by 11/01/20, hospitalization, ICU admission, or death within 60 days of a positive test. Main predictors were any ICD-10-CM SUDs, with substance-specific SUDs (cannabis, cocaine, opioid, stimulant, sedative) explored individually. Logistic regression produced unadjusted and covariate-adjusted odds ratios (OR; aOR).ResultsAmong COVID-19+ patients, 19.25% were hospitalized, 7.71% admitted to ICU, and 5.84% died. In unadjusted models, any SUD and all substance-specific SUDs except cannabis use disorder were associated with COVID-19+(ORs=1.06-1.85); adjusted models produced similar results. Any SUD and all substance-specific SUDs were associated with hospitalization (aORs: 1.24-1.91). Any SUD, cocaine and opioid disorder were associated with ICU admission in unadjusted but not adjusted models. Any SUD, cannabis, cocaine, and stimulant disorders were inversely associated with mortality in unadjusted models (OR=0.27-0.46). After adjustment, associations with mortality were no longer significant. In ad hoc analyses, adjusted odds of mortality were lower among the 49.9% of COVID-19+ patients with SUD who had SUD treatment in 2019, but not among those without such treatment.ConclusionsIn VHA patients, SUDs are associated with COVID-19 hospitalization but not COVID-19 mortality. SUD treatment may provide closer monitoring of care, ensuring that these patients received needed medical attention, enabling them to ultimately survive serious illness.

AbstractChronic pain is associated with mental and physical health difficulties and is prevalent among veterans. Cannabis has been put forth as a treatment for chronic pain, and changes in laws, attitudes, and use patterns have occurred over the past 2 decades. Differences in prevalence of nonmedical cannabis use and cannabis use disorder (CUD) were examined across 2 groups: veterans or nonveterans and those reporting or not reporting recent pain. Data from the National Epidemiologic Survey on Alcohol and Related Conditions-III (2012-2013; n = 36,309) were analyzed using logistic regression. Prevalence differences (PDs) for 3 cannabis outcomes (1) past-year nonmedical cannabis use, (2) frequent (≥3 times a week) nonmedical use, and (3) DSM-5 CUD were estimated for those reporting recent moderate to severe pain (veterans or nonveterans) and veterans reporting or not reporting recent pain. Difference in differences was calculated to investigate PDs on outcomes associated with residence in a state with medical cannabis laws (MCLs). Associations between physical and mental health and cannabis variables were tested. The results indicated that the prevalence of recent pain was greater among veterans (PD = 7.25%, 95% confidence interval (CI) [4.90-9.60]). Among veterans, the prevalence of frequent cannabis use was greater among those with pain (PD = 1.92%, 98% CI [0.21-3.63]), and among veterans residing in a state with MCLs, the prevalence of CUD was greater among those reporting recent pain (PD = 3.88%, 98% CI [0.36-7.39]). Findings failed to support the hypothesis that cannabis use improves mental or physical health for veterans with pain. Providers treating veterans with pain in MCL states should monitor such patients closely for CUD.

ObjectiveThe Department of Veterans Affairs' (VA) electronic health records (EHR) offer a rich source of big data to study medical and health care questions, but patient eligibility and preferences may limit generalizability of findings. We therefore examined the representativeness of VA veterans by comparing veterans using VA healthcare services to those who do not.MethodsWe analyzed data on 3051 veteran participants age ≥ 18 years in the 2019 National Health Interview Survey. Weighted logistic regression was used to model participant characteristics, health conditions, pain, and self-reported health by past year VA healthcare use and generate predicted marginal prevalences, which were used to calculate Cohen's d of group differences in absolute risk by past-year VA healthcare use.ResultsAmong veterans, 30.4% had past-year VA healthcare use. Veterans with lower income and members of racial/ethnic minority groups were more likely to report past-year VA healthcare use. Health conditions overrepresented in past-year VA healthcare users included chronic medical conditions (80.6% vs. 69.4%, d = 0.36), pain (78.9% vs. 65.9%; d = 0.35), mental distress (11.6% vs. 5.9%; d = 0.47), anxiety (10.8% vs. 4.1%; d = 0.67), and fair/poor self-reported health (27.9% vs. 18.0%; d = 0.40).ConclusionsHeterogeneity in veteran sociodemographic and health characteristics was observed by past-year VA healthcare use. Researchers working with VA EHR data should consider how the patient selection process may relate to the exposures and outcomes under study. Statistical reweighting may be needed to generalize risk estimates from the VA EHR data to the overall veteran population.

Since DSM-IV was published in 1994, its approach to substance use disorders has come under scrutiny. Strengths were identified (notably, reliability and validity of dependence), but concerns have also arisen. The DSM-5 Substance-Related Disorders Work Group considered these issues and recommended revisions for DSM-5. General concerns included whether to retain the division into two main disorders (dependence and abuse), whether substance use disorder criteria should be added or removed, and whether an appropriate substance use disorder severity indicator could be identified. Specific issues included possible addition of withdrawal syndromes for several substances, alignment of nicotine criteria with those for other substances, addition of biomarkers, and inclusion of nonsubstance, behavioral addictions.This article presents the major issues and evidence considered by the work group, which included literature reviews and extensive new data analyses. The work group recommendations for DSM-5 revisions included combining abuse and dependence criteria into a single substance use disorder based on consistent findings from over 200,000 study participants, dropping legal problems and adding craving as criteria, adding cannabis and caffeine withdrawal syndromes, aligning tobacco use disorder criteria with other substance use disorders, and moving gambling disorders to the chapter formerly reserved for substance-related disorders. The proposed changes overcome many problems, while further studies will be needed to address issues for which less data were available.

Alcohol consumption is common across subpopulations in the United States. However, the health burden associated with alcohol consumption varies across groups, including those defined by demographic characteristics such as age, [...]

Exposure to varying forms of stress is an integral life experience that can provoke a variety of reactions. In research on alcohol, drug, and psychiatric disorders, the term 'stress' often [...]

Objectives. We examined the relation between living in states that instituted bans on same-sex marriage during the 2004 and 2005 elections and the prevalence of psychiatric morbidity among lesbian, gay, and bisexual (LGB) populations. Methods. We used data from wave 1 (2001-2002) and wave 2 (2004-2005) of the National Epidemiologic Survey on Alcohol and Related Conditions (N=34653), a longitudinal, nationally representative study of noninstitutionalized US adults. Results. Psychiatric disorders defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, increased significantly between waves 1 and 2 among LGB respondents living in states that banned gay marriage for the following outcomes: any mood disorder (36.6% increase), generalized anxiety disorder (248.2% increase), any alcohol use disorder (41.9% increase), and psychiatric comorbidity (36.3% increase). These psychiatric disorders did not increase significantly among LGB respondents living in states without constitutional amendments. Additionally, we found no evidence for increases of the same magnitude among heterosexuals living in states with constitutional amendments. Conclusions. Living in states with discriminatory policies may have pernicious consequences for the mental health of LGB populations. These findings lend scientific support to recent efforts to overturn these policies. (Am J Public Health. 2010;100:452-459. doi: 10.2105/AJPH.2009.168815)

Objectives. We investigated the modifying effect of state-level policies on the association between lesbian, gay, or bisexual status and the prevalence of psychiatric disorders. Methods. Data were from wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a nationally representative study of noninstitutionalized US adults (N=34653). States were coded for policies extending protections against hate crimes and employment discrimination based on sexual orientation. Results. Compared with living in states with policies extending protections, living in states without these policies predicted a significantly stronger association between lesbian, gay, or bisexual status and psychiatric disorders in the past 12 months, including generalized anxiety disorder (F=3.87; dr=2; P=.02), post-traumatic stress disorder (F=3.42; dr=2; P=.04), and dysthymia (F=5.20; df=2; P=.02). Living in states with policies that did not extend protections also predicted a stronger relation between lesbian, gay, or bisexual status and psychiatric comorbidity (F=2.47; dr=2; P=.04). Conclusions. State-level protective policies modify the effect of lesbian, gay, or bisexual status on psychiatric disorders. Policies that reduce discrimination against gays and lesbians are urgently needed to protect the health and well-being of this population. (Am J Public Health. 2009;99:2275-2281. doi: 10.2105/AJPH.2008.153510)

Objectives. We examined the roles of gender and poverty in cigarette use and nicotine dependence among adults in the United States. Methods. Our data were drawn from the 2001-2002 National Epidemiological Survey of Alcoholism and Related Conditions, a nationally representative sample of US adults 18 years and older. Results. The overall rate of cigarette use declined between 1964 and 2002. Nicotine dependence does not appear to have declined overall, and there is evidence that nicotine dependence has increased among women in recent cohorts. The odds of nicotine dependence among cigarette users appear to have increased significantly in recent cohorts. Conclusions. Despite recent declines in cigarette use, the prevalence of nicotine dependence has increased among some groups and has remained steady overall, which may be hampering public health initiatives to reduce cigarette use. Efforts to study or curb cigarette use should therefore take nicotine dependence into account. (doi:10.2105/AJPH.2007.127886)

Objectives. We sought to study the association between adverse events occurring in childhood and adolescence and lifetime alcohol dependence in a representative sample of American adults. Methods. With data from the National Epidemiologic Survey on Alcohol and Related Conditions, we conducted logistic regression multivariate analyses to examine the impact of adverse events occurring in childhood (aged Results. Adverse childhood events were associated with familial alcoholism and with early and binge drinking, and therefore, we controlled for these potential confounders. Experiencing 2 or more adverse childhood events, compared with none, significantly increased the risk for alcohol dependence, even after we controlled for sociodemographic variables and disorder-specific potential confounders not considered in the extant literature (adjusted odds ratio = 1.37; 95% confidence interval = 1.06, 1.77). Conclusions. Individuals who experienced 2 or more adverse childhood events are at increased risk for lifetime alcohol dependence. A better understanding of the factors underlying the risk for alcohol dependence is important for developing better prevention and early intervention measures. (Am J Public Health. 2009;99:258-263. doi:10.2105/AJPH.2008.139006)

Objectives. We examined the effects of exposure to or interpersonal loss resulting from a terrorist attack on posttraumatic stress and alcohol consumption after we controlled for psychiatric history assessed before the attack. Methods. At baseline (1991-1992) and at 1- and 10-year follow-ups, an adult community sample of drinkers living approximately 12 mi (19.2 km) from the World Trade Center were evaluated for alcohol dependence and major depression. Of this group, 82.2% were assessed regarding the impact of the September 11, 2001, attacks, including proximity to the World Trade Center, interpersonal loss, posttraumatic stress, and alcohol consumption. Results. In regression models, interpersonal loss and past major depression, but not proximity to the World Trade Center, predicted posttraumatic stress symptoms. Proximity and past alcohol dependence, but not interpersonal loss, predicted high levels of post--September 11 alcohol consumption. Past alcohol dependence did not modify the proximity-drinking relationship, and past major depression did not modify the loss--posttraumatic stress relationship. Conclusions. Participants' responses to September 11 were specific to their type of exposure and not predetermined by their psychiatric history. A better understanding of responses to traumatic events should assist more-effective prevention and intervention efforts.

Objectives. We investigated the consequences of exposure to acts of terrorism among Israeli adolescents. We examined Whether exposure to terrorism predicted adolescents' use of cigarettes, alcohol (including binge drinking), and cannabis after we controlled for posttraumatic stress and depressive symptoms and background variables. Methods. Anonymous self-administered questionnaires were given to a random sample of 960 10th and 11th grade students (51.6% boys, 48.4% girls) in a large city in northern Israel. Results. Close physical exposure to acts of terrorism predicted higher levels of alcohol consumption (including binge drinking among drinkers) and cannabis use. These relationships remained even after we controlled for posttraumatic stress and depressive symptoms. Conclusions. In addition to posttraumatic stress symptoms, negative consequences of terrorism exposure among adolescents included substance abuse. The similarity between our findings among Israeli adolescents and previous findings among US adults suggests cross-cultural generalizability. Given the risks for later problems from early-onset substance abuse, the consequences of terrorism exposure among adolescents merit greater research and clinical attention. (Am J Public Health. 2007;97:1852-1858. doi:10.2105/AJPH.2006.090514)

Objectives. We examined risk factors for long-term homelessness among newly homeless men and women who were admitted to New York City shelters in 2001 and 2002. Methods. Interviews were conducted with 377 study participants upon entry into the shelter and at 6-month intervals for 18 months. Standardized assessments of psychiatric diagnosis, systoms, and coping skills; social and family history; and service use were analyzed. Kaplan-Meier survival analysis and Cox regression were used to examine the association between baseline assessments and duration of homelessness. Results. Eighty-one percent of participants returned to community housing during the follow-up period; the meridian duration of homelessness was 190 days. Kaplan-Meier survival analysis showed that a shorter duration of homelessness was associated with younger age, current or recent employment, earned income, good coping skills, adequate family support, absence of a substance abuse treatment history, and absence of an arrest history. Cox regression showed that older age group (P Conclusions. Identification of risk factors for long-term homelessness can guide efforts to reduce lengths of stay in homeless shelters and to develop new preventive interventinos. (Am J Public Health. 2005;95: 1753-1759. doi: 10.2105/AJPH. 2005.063321)

Researchers and clinicians usually diagnose alcohol problems using standardized interviews. These can be structured, in which interviewers read questions to subjects and transcribe answers, or unstructured, in which interviewers probe […]