Mental and Physical Health Conditions Among U.S. Veterans with Cannabis Use and Cannabis Use Disorders

Purpose of Review

Veterans are a large population that is disproportionately affected by various physical and mental health conditions. The primary aim of this review is to provide a concise overview of recent literature on the prevalence of cannabis use and cannabis use disorder (CUD) among US Veterans, and associations with mental and physical health conditions. We also addressed gaps in the literature by investigating associations between CUD and mental and physical health conditions in 2019 data from the Veterans Health Administration (VHA; N=5,657,277).

Recent Findings

In total, 25 studies were reviewed. In 2019, the prevalence of Veteran cannabis use ranged from 11.9%-18.7%. Cannabis use and CUD were associated with bipolar disorders, psychotic disorders, suicidality, pain conditions, and other substance use, but less consistently associated with depressive disorders, anxiety disorders, and posttraumatic stress disorder. Analyses of 2019 VHA data indicated that CUD was strongly associated with a broad array of physical and mental health conditions and mortality.

Summary

Cannabis use and CUD are prevalent and highly comorbid with other conditions among US Veterans. Harm reduction methods tailored to these populations are needed.

Alcohol use in emerging adults associated with lower rich-club connectivity and greater connectome network disorganization

BACKGROUND

Emerging adulthood is a critical neurodevelopmental stage, with alcohol use during this period consistently associated with brain abnormalities and damage in anatomical structure and white matter integrity. However, it is less clear how alcohol use is associated with the brain's structural organization (i.e., white matter connections between anatomical regions). Recent connectome research has focused on rich-club regions, a collection of highly-interconnected hubs that are critical in brain communication and global network organization and disproportionately vulnerable to insults.

METHODS

For the first time, we examined alcohol use associations with structural rich-club and connectome organization in emerging adults (N = 66).

RESULTS

Greater lifetime drinks and current monthly drinks were significantly associated with lower rich-club organization (r_s =-0.38, ps < 0.003) and lower rich-club connectivity (r_s <-0.34, ps < 0.007). Additionally, rich-club connectivity was significantly more negatively correlated with alcohol use than connectivity among non-rich-club regions (ps < 0.035). Examining overall structural organization, greater lifetime drinks and current monthly drinks were significantly associated with lower network density (i.e., lower network resilience; r_s <-0.36, ps = 0.004). Additionally, greater lifetime drinks and current monthly drinks were significantly associated with higher network segregation (i.e., network's tendency to divide into subnetworks; r_s >0.33, ps<0.008). Alcohol use was not significantly associated with network integration (i.e., network's efficiency in combining information across the brain; ps > 0.064).

CONCLUSIONS

Results provide novel evidence that alcohol use is associated with decreased rich-club connectivity and structural network disorganization. Given that both are critical in global brain communication, these results highlight the importance of examining alcohol use and brain relationships in emerging adulthood.

Prospective Study Examining the Effects of Extreme Drinking on Brain Structure in Emerging Adults

BACKGROUND

Emerging adulthood is a critical neurodevelopment period in which extreme drinking has a potentially pronounced neurotoxic effect. Therefore, extreme drinking, even a single episode, could be particularly harmful to the developing brain's structure. Relatedly, heavy alcohol use in emerging adults has been associated with structural brain damage, especially in the corpus callosum. However, it is unclear whether and how much a single extreme drinking episode would affect brain morphometry.

METHODS

For the first time in the literature, the current study prospectively examined the impact of an extreme drinking episode (i.e., twenty-first birthday celebration) on the brain morphometry of emerging adults immediately following their birthday celebration (n = 50) and approximately 5 weeks post-birthday celebration (n = 29).

RESULTS

We found evidence that a single extreme drinking episode was associated with structural changes immediately post-birthday celebration. Specifically, higher twenty-first birthday estimated blood-alcohol concentration was associated with decreased volume of the posterior and central corpus callosum immediately post-birthday celebration. This extreme drinking episode was not associated with further structural changes, or recovery, 5 weeks post-twenty-first birthday celebration.

CONCLUSIONS

Overall, results suggest that a single episode of heavy drinking in emerging adulthood may be associated with immediate structural changes of the corpus callosum. Thus, emerging adulthood, which is characterized by high rates of extreme drinking, could be a critical period for targeted prevention and intervention.

Twenty-first birthday drinking: Extreme-drinking episodes and white matter microstructural changes in the fornix and corpus callosum

The 21st birthday celebration is characterized by extreme alcohol consumption. Accumulating evidence suggests that high-dose bingeing is related to structural brain changes and cognitive deficits. This is particularly problematic in the transition from adolescence to adulthood when the brain is still maturing, elevating the brain's sensitivity to the acute effects of alcohol intoxication. Heavy drinking is associated with reduced structural integrity in the hippocampus and corpus callosum and is accompanied by cognitive deficits. However, there is little research examining changes in the human brain related to discrete heavy-drinking episodes. The present study investigated whether alcohol exposure during a 21st birthday celebration would result in changes to white matter microstructure by utilizing diffusion tensor imaging measures and a quasi-experimental design. By examining structural changes in the brain from pre- to postcelebration within subjects (N = 49) prospectively, we were able to more directly observe brain changes following an extreme-drinking episode. Region of interest analyses demonstrated increased fractional anisotropy in the posterior fornix (p < .0001) and in the body of the corpus callosum (p = .0029) from pre- to postbirthday celebration. These results suggest acute white matter damage to the fornix and corpus callosum following an extreme-drinking episode, which is especially problematic during continued neurodevelopment. Therefore, 21st birthday drinking may be considered an important target event for preventing acute brain injury in young adults. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Alcohol use in young adults associated with cortical gyrification

BACKGROUND

Young adulthood has the highest rates of alcohol use and high-risk drinking behavior. This period is also a critical neurodevelopmental stage, with neural insults having a profound neurotoxic effect on the brain. Cortical gyrification is thought, in part, to reflect early brain maturation (e.g., hypogyrification in fetal alcohol syndrome). There is also evidence that cortical gyrification is sensitive to later-life events (e.g., fluctuations in malnutrition in young adults). However, no study has examined how alcohol use in young adulthood is associated with cortical gyrification.

METHODS

We examined the associations between cortical gyrification with lifetime alcohol use and past year hangover symptoms in young adults (N = 78).

RESULTS

Lifetime alcohol use was associated with hypogyria in multiple cortical regions (rs ≤ -.27, ps ≤ .0159; right orbitofrontal, right temporal pole, and left lateral occipital). Further, past year hangover symptoms were associated with hypogyria (rs ≤ -.27, ps ≤ .0034), overlapping with lifetime alcohol use (right orbitofrontal and left lateral occipital). Hangover symptoms were also uniquely associated with hypogyria of other cortical regions (rs ≤ -.30, ps ≤ .0002; right parahippocampal gyrus, left inferior temporal/parahippocampal gyrus and right anterior insula).

CONCLUSIONS

Thus, results suggest that young adulthood is a critical period for targeted prevention and intervention, especially for individuals exhibiting heavy alcohol consumption and high-risk drinking behavior.

Training Health Services Psychologists for Research Careers in Addiction Science

Addiction is a growing public health crisis, yet comparatively very few health services psychology programs include formal training in addiction science (Dimoff, Sayette, Norcross, 2017). Health services psychologists (i.e., psychologists who integrate psychological science and practice to understand development and functioning; APA, 2015) are well-suited to study and treat addiction, and doctoral level training is an ideal time to prepare future health services psychologists to do so. One possible barrier to incorporating addiction science training is the necessity of a multidisciplinary approach to study and treat addiction and related health behaviors. We focus primarily on clinical science training and argue for a multi-faceted approach to doctoral training in addiction science that would prepare trainees for research careers. The proposed training model emphasizes the importance of mentorship, coursework, grant preparation, responsible conduct of research, prevention, intervention, and treatment, and invited speakers and conference attendance. Each of these components is discussed with an emphasis on addiction science. We offer suggestions for incorporating portions of this training model for programs with few addiction science related resources. We also discuss the importance of enhancing diversity and inclusion in addiction training and offer brief recommendations on this topic.

Religious involvement and racial disparities in opioid use disorder between 2004-2005 and 2012-2013: Results from the National Epidemiologic Survey on Alcohol and Related Conditions

BACKGROUND

Psychosocial factors have rarely been studied to understand racial differences in opioid use disorders (OUD). We investigate religious involvement and Black-White differences in OUD risk between 2004-05 and 2012-13.

METHODS

We use Non-Hispanic Black and White adults from the National Epidemiologic Survey on Alcohol and Related Conditions (wave 2, N = 26,661 and NESARC-III, N = 26,960) (NESARC). We conducted survey-weighted logistic regression to examine whether race moderates the association between religious involvement and lifetime DSM-IV and -5 OUD and whether those differences change (i.e., are modified) by time, adjusted for covariates such as age, education, and urbanicity. Religious involvement measures were service attendance, social interaction, and subjective religiosity/spirituality.

RESULTS

The prevalence of lifetime DSM-IV (3.82 vs 1.66) and DSM-5 (2.49 vs 1.32) OUD in NESARC-III was higher among White compared to Black respondents. Never attending services declined for both races over time. Race moderated the association between service attendance (F(4,65) = 14.9, p = 0.000), social interaction (F(4,65) = 34.4, p = 0.000) and subjective religiosity/spirituality (F(2,65) = 7.03, p = 0.000) on DSM-IV OUD in wave 2 and using DSM-5 OUD in NESARC-III (F(1,113) = 2.79, p = 0.066). Race differences in religion and DSM-IV OUD risk was modified by time (i.e., survey year) (all p < 0.000). For instance, higher service attendance was associated with lower DSM-IV risk for Black respondents in wave 2 but higher risk in NESARC-III. There were no changes in regression slopes among White respondents.

CONCLUSIONS

Religious involvement may be important for prevention and treatment practices that respond to racial differences in risk of OUD. Replicate studies should examine other religious factors and specific types of opioids.

Toward more efficient diagnostic criteria sets and rules: The use of optimization approaches in addiction science

Psychiatric diagnostic systems, such as The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), use expert consensus to determine diagnostic criteria sets and rules (DCSRs), rather than exploiting empirical techniques to arrive at optimal solutions (OS). Our project utilizes complete enumeration (i.e., generating all possible subsets of item combinations A and B with all possible thresholds, T) to evaluate all possible DCSRs given a set of relevant diagnostic data. This method yields the entire population distribution of diagnostic classifications (i.e., diagnosis of the disorder versus no diagnosis) produced by a set of dichotomous predictors (i.e., diagnostic criteria). Once unique sets are enumerated, optimization on some predefined correlate or predictor will maximally separate diagnostic groups on one or more, disorder-specific "outcome" criteria. We used this approach to illustrate how to create a common Substance Use Disorder (SUD) DCSR that is applicable to multiple substances. We demonstrate the utility of this approach with respect to alcohol use disorder and Cannabis Use Disorder (CUD) using DSM-5 criteria as input variables. The optimal SUD solution with a moderate or above severity grading included four criteria (i.e. 1) having a strong urge or craving for the substance (CR), 2) failure to fulfill major role obligations at work school or home (FF), 3) continued use of the substance despite social or interpersonal problems caused by the substance use (SI) and 4) physically hazardous use (HU)) with a diagnostic threshold of two. The derived DCSR was validated with known correlates of SUD and performed as well as DSM-5. Our findings illustrate the value of using an empirical approach to what is typically a subjective process of choosing criteria and algorithms that is prone to bias. The optimization of diagnostic criteria can reduce criteria set sizes, resulting in decreased research, clinician, and patient burden.

Are Some Alcohol Use Disorder Criteria More (or Less) Externalizing than Others? Distinguishing Alcohol Use Symptomatology from General Externalizing Psychopathology

BACKGROUND

The externalizing spectrum contains a range of disinhibition-related conditions, such as conduct disorder, antisocial personality disorder, and substance use disorders. Comorbidity among externalizing disorders is commonly investigated at the syndromal and trait level precluding insight into the relationship of symptoms across externalizing disorders. It is unknown whether comorbidity across externalizing disorders holds constant across highly varied, individual alcohol use disorder (AUD) criteria. AUD criteria range from symptoms reflecting neuroadaptation (e.g., tolerance) to symptoms reflecting behavioral problems (e.g., social problems). The present study aimed to determine the degree to which individual AUD criteria are associated with symptomatology from other externalizing disorders. Characterization of the degree to which AUD criteria reflect neuroadaptation versus behavioral problems can be used to identify symptom profiles, which, in turn, can be used to inform diagnostic and treatment approaches.

METHODS

Data from 2 large nationally representative samples were used to examine associations between AUD criteria and externalizing behavior. Psychometric inquiries via multivariate and factor analytic approaches estimated relative associations of externalizing behavior and AUD criteria endorsement, as compared to alcohol consumption.

RESULTS

Our results indicate differential relations of externalizing behavior and AUD criteria endorsement. For example, social problems and role interference criteria were most strongly associated with externalizing behavior across analytic approaches, with general and unique associations with externalizing behavior. Additionally, tolerance was most weakly associated with externalizing behavior across approaches.

CONCLUSIONS

Results highlight potential etiological heterogeneity among AUD criteria that could guide future diagnostic refinements and aid in the identification of treatment targets.

Trends in Adult Alcohol Use and Binge Drinking in the Early 21st-Century United States: A Meta-Analysis of 6 National Survey Series

BACKGROUND

Recent trends in alcoholic liver disease, alcohol-related emergency room admissions, and alcohol use disorder prevalence as measured by general-population surveys have raised concerns about rising alcohol-related morbidity and mortality in the United States. In contrast, upward trends in per capita alcohol consumption have been comparatively modest.

METHODS

To resolve these discordant observations, we sought to examine trends in the prevalence of alcohol use and binge drinking from 6 regularly or periodically administered national surveys using a meta-analytic approach. Annual or periodic prevalence estimates for past-12-month or past-30-day alcohol use and binge drinking were estimated for available time points between the years 2000 and 2016. Estimates were combined in a random-effects regression model in which prevalence was modeled as a log-linear function of time to obtain meta-analytic trend estimates for the full population and by sex, race, age, and educational attainment.

RESULTS

Meta-analysis-derived estimates of average annual percentage increase in the prevalence of alcohol use and binge drinking were 0.30% per year (95% CI: 0.22%, 0.38%) and 0.72% per year (95% CI: 0.46%, 0.98%), respectively. There was substantial between-survey heterogeneity among trend estimates, although there was notable consistency in the degree to which trends have impacted various demographic groups. For example, most surveys found that the changes in prevalence for alcohol use and binge drinking were large and positive for ages 50 to 64 and 65 and up, and smaller, negative, or nonsignificant for ages 18 to 29.

CONCLUSIONS

Significant increases in the prevalence of alcohol use and of binge drinking over the past 10 to 15 years were observed, but not for all demographic groups. However, the increase in binge drinking among middle-aged and older adults is substantial and may be driving increasing rates of alcohol-related morbidity and mortality.

Desistance and Severity of Alcohol Use Disorder: A Lifespan-Developmental Investigation

Key to an understanding of alcohol use disorder (AUD) are the drinking-related reductions that begin in young adulthood and continue throughout the adult lifespan. Research is needed to precisely characterize the form of these reductions, including possible developmental differences across the lifespan. Using U.S.-representative data, we estimated multiple-group Markov models characterizing longitudinal transitions among five drinking statuses and differences in transition patterns across six adult age periods. While past research indicates relative developmental stability in overall AUD-desistance rates, we found far higher rates of Severe-AUD desistance in young adulthood relative to later ages. Especially considering the dramatic change reflected by Severe-AUD desistance (from 6+ symptoms to 0-1 symptoms), this result indicates a substantial developmental shift, with Severe-AUD-desistance rates peaking at 43-50% across ages 25-34 and then dropping to 22-24% across ages 35-55. We discuss implications regarding practical significance of young-adult "maturing out" and predictions regarding lifespan variability in desistance mechanisms.