"That's Pot Culture Right There": Purchasing Behaviors of People Who Use Cannabis Without a Medical Cannabis Card.

Introduction: The legal landscape surrounding purchasing cannabis without a medical cannabis card (i.e., without MCC) is changing rapidly, affecting consumer access and purchasing behaviors. Cannabis purchasing behaviors are related to subsequent use and experiencing greater cannabis-related negative consequences. However, purchasing behaviors of individuals who use cannabis without MCC are understudied. Methods: The current study analyzed qualitative data from focus groups with adults who use cannabis without MCC (n = 5 groups; 6-7 participants/group; n = 31 total participants). Focus groups followed a semi-structured agenda, and were audio recorded and transcribed. Two coders applied thematic analysis to summarize topics pertaining to cannabis purchasing attitudes and behaviors. Focus groups occurred in 2015 and 2016 in Rhode Island, when purchasing and use of cannabis without MCC was decriminalized but still considered illegal. Results: On average, participants (72% male) were 26 years old (SD = 7.2) and reported using cannabis 5 days per week (SD = 2.1). Thematic analysis revealed three key themes related to cannabis purchasing behaviors: (1) regular purchasing routines (i.e., frequency, schedule, amount of purchases), (2) economic factors (i.e., financial circumstances), and (3) contextual factors (i.e., quality of cannabis, convenience/availability) were perceived to influence purchasing decisions. Dealers' recommendations affected participants' purchases, who also reported minimal legal concerns. Participants reported saving money and using more cannabis when buying in bulk. Discussion: Purchasing behaviors were found to vary and were perceived to be affected by individual-level (e.g., routines) and contextual factors (e.g., availability) that, in turn, may impact use patterns. Future research should consider how factors (e.g., availability) that differ across contexts (e.g., location) and demographic groups interact to affect purchasing behaviors.

Cannabis Use Patterns and Whole-Blood Cannabinoid Profiles of Emergency Department Patients With Suspected Cannabinoid Hyperemesis Syndrome.

STUDY OBJECTIVES: The objectives of this study were to characterize the detailed cannabis use patterns (eg, frequency, mode, and product) and determine the differences in the whole-blood cannabinoid profiles during symptomatic versus asymptomatic periods of participants with suspected cannabinoid hyperemesis syndrome recruited from the emergency department (ED) during a symptomatic episode. METHODS: This is a prospective observational cohort study of participants with symptomatic cyclic vomiting onset after chronic cannabis use. Standardized assessments were conducted to evaluate for lifetime and recent cannabis use, cannabis use disorder, and cannabis withdrawal symptoms. Quantitative whole-blood cannabinoid testing was performed at 2 times, first when symptomatic (ie, baseline) and at least 2 weeks after the ED visit when asymptomatic. The differences in cannabinoid concentrations were compared between symptomatic and asymptomatic testing. The study was conducted from September 2021 to August 2022. RESULTS: There was a difference observed between delta-9-tetrahydrocannabinol metabolites, but not the parent compound during symptomatic episodes and asymptomatic periods. Most participants (84%) reported using cannabis > once per day (median 3 times per day on weekdays, 4 times per day on weekends). Hazardous cannabis use was universal among participants; the mean cannabis withdrawal discomfort score was 13, indicating clinically significant rates of cannabis withdrawal symptoms with cessation of use. Most participants (79%) previously tried to stop cannabis use, but a few (13%) of them had sought treatment. CONCLUSION: Patients presenting to the ED with cannabinoid hyperemesis syndrome have high cannabis use disorder scores. Further studies are needed to better understand the influence of THC metabolism and concentrations on symptomatic cyclic vomiting.

Cannabinoid hyperemesis syndrome: clinical trajectories and patterns of use three months following a visit to the emergency department.

OBJECTIVES: Cannabinoid hyperemesis syndrome (CHS) is a clinical condition of cyclic vomiting, nausea, and abdominal pain associated with chronic cannabis use. Despite increased recognition of CHS, there are limited details on cannabis use practices and symptoms over time. Understanding what happens in the period surrounding the ED visit, including any changes in symptoms and cannabis use practices following the visit, can help inform the development of patient-centered interventions around cannabis use disorder for patients with CHS. METHODS: A prospective observational cohort (n=39) of patients with suspected CHS recruited from the Emergency Department (ED) at the time of a symptomatic cyclic vomiting episode was followed for three months. Disease progression, cannabis use practices, and health care utilization were monitored. RESULTS: Participants reported high rates of persistent CHS symptoms (abdominal pain, nausea, or cyclic vomiting) in the two-week period immediately following an ED visit with a median duration of 7 days. Cannabis use frequency and quantity were reduced immediately after the ED visit, but most participants returned to pre-ED visit cannabis use patterns within a few days. Recurrent ED visits for cyclic vomiting were reported by 25% of participants who completed follow-up during the three month follow up period. CONCLUSIONS: Participants continued to have ongoing symptoms after the ED visit, but most manage symptoms on their own and do not return to the ED. Longitudinal studies beyond three months are needed to better understand the clinical course of patients with suspected CHS.

Effect of Cognitive Behavioral Therapy for Insomnia on Alcohol Treatment Outcomes Among US Veterans: A Randomized Clinical Trial.

Importance: Three of 4 adults in treatment for alcohol use disorder (AUD) report symptoms of insomnia. Yet the first-line treatment for insomnia (cognitive behavioral therapy for insomnia, CBT-I) is often delayed until abstinence is established. Objective: To test the feasibility, acceptability, and preliminary efficacy of CBT-I among veterans early in their AUD treatment and to examine improvement in insomnia as a mechanism for improvement in alcohol use outcomes. Design, Setting, and Participants: For this randomized clinical trial, participants were recruited through the Addictions Treatment Program at a Veterans Health Administration hospital between 2019 and 2022. Patients in treatment for AUD were eligible if they met criteria for insomnia disorder and reported alcohol use in the past 2 months at baseline. Follow-up visits occurred posttreatment and at 6 weeks. Interventions: Participants were randomly assigned to receive 5 weekly sessions of CBT-I or a single session about sleep hygiene (control). Participants were asked to complete sleep diaries for 7 days at each assessment. Main Outcomes and Measures: Primary outcomes included posttreatment insomnia severity (assessed using the Insomnia Severity Index) and follow-up frequency of any drinking and heavy drinking (4 drinks for women, ≥5 drinks for men; number of days via Timeline Followback) and alcohol-related problems (Short Inventory of Problems). Posttreatment insomnia severity was tested as a mediator of CBT-I effects on alcohol use outcomes at the 6-week follow-up. Results: The study cohort included 67 veterans with a mean (SD) age of 46.3 years (11.8); 61 (91%) were male and 6 (9%) female. The CBT-I group included 32 participants, and the sleep hygiene control group 35 participants. Of those randomized, 59 (88%) provided posttreatment or follow-up data (31 CBT-I, 28 sleep hygiene). Relative to sleep hygiene, CBT-I participants reported greater decreases in insomnia severity at posttreatment (group × time interaction: -3.70; 95% CI, -6.79 to -0.61) and follow-up (-3.34; 95% CI, -6.46 to -0.23) and greater improvements in sleep efficiency (posttreatment, 8.31; 95% CI, 1.35 to 15.26; follow-up, 18.03; 95% CI, 10.46 to 25.60). They also reported greater decreases in alcohol problems at follow-up (group × time interaction: -0.84; 95% CI, -1.66 to -0.02), and this effect was mediated by posttreatment change in insomnia severity. No group differences emerged for abstinence or heavy-drinking frequency. Conclusions and Relevance: In this randomized clinical trial, CBT-I outperformed sleep hygiene in reducing insomnia symptoms and alcohol-related problems over time but had no effect on frequency of heavy drinking. CBT-I should be considered a first-line treatment for insomnia, regardless of abstinence. Trial Registration: ClinicalTrials.gov Identifier: NCT03806491.

Dynamic relations among simultaneous alcohol and cannabis use, subjective responses, and problem drinking during naturally occurring drinking episodes.

BACKGROUND: Simultaneous alcohol and cannabis use (SAM) is associated with riskier drinking. However, little is known regarding mechanisms of risk during drinking episodes. The current study tested whether subjective responses to simultaneous vs. alcohol-only use (i.e., high arousal positive/reward, high arousal negative/aggression, low arousal positive/relaxation, low arousal negative/impairment) were mechanisms through which SAM use was associated with daily drinking. METHODS: Emerging adults who co-use alcohol and cannabis (N=85) completed 21 days of ecological momentary assessment with drink-contingent reports during drinking episodes. Participants reported on their simultaneous use and current subjective effects during drink reports and past-night total drinks consumed and negative consequences experienced the next morning. Three-level multilevel models (momentary, daily, person level) tested whether SAM use predicted subjective responses, and whether subjective responses mediated associations between SAM use, heavier drinking and negative consequences. RESULTS: At the momentary and day-level, SAM (vs. alcohol-only) use predicted increased high arousal positive/rewarding, low arousal positive/relaxing, and low arousal negative/impairing subjective effects. SAM use indirectly predicted heavier day-level drinking and further negative consequences through high arousal positive/rewarding response. SAM use also indirectly predicted day-level negative consequences through low arousal negative/impairing response. At the person-level, more frequent SAM use predicted higher person-average high arousal positive/rewarding and low arousal positive/relaxing responses, and high arousal positive/rewarding response mediated relation between SAM frequency and heavier drinking. CONCLUSIONS: Simultaneous use was associated with reward, relief, and impairment, and reward and impairment were mechanisms of risk between SAM use and riskier drinking. Findings may inform theory and just-in-time interventions seeking to reduce alcohol misuse.

Prospective Associations Between Anxiety Sensitivity, Distress Intolerance, Depressive Symptoms, and Indices of Alcohol and Cannabis Use Among Veterans.

OBJECTIVE: There is substantial evidence linking anxiety sensitivity and distress intolerance to depressive symptoms, and further evidence linking depressive symptoms to alcohol and cannabis use. However, the prospective indirect associations of anxiety sensitivity and distress intolerance with alcohol and cannabis use through depressive symptoms remain uncertain. Thus, the current study examined whether depressive symptoms mediated the associations between anxiety sensitivity and distress intolerance with alcohol and cannabis use frequency, quantity, and problems in a longitudinal sample of veterans. METHOD: Participants (N = 361; 93% male; 80% White) were military veterans with lifetime cannabis use recruited from a Veterans Health Administration in the Northeastern United States. Eligible veterans completed three semi-annual assessments. Prospective mediation models were used to test for the effects of baseline anxiety sensitivity and distress intolerance on alcohol and cannabis use quantity, frequency and problems at 12 months via depressive symptoms at 6 months. RESULTS: Baseline anxiety sensitivity was positively associated with 12-month alcohol problems. Baseline distress intolerance was positively associated with 12-month cannabis use frequency and quantity. Baseline anxiety sensitivity and distress intolerance significantly predicted increased alcohol problems and cannabis use frequency at 12 months through depressive symptoms at 6 months. There were no significant indirect effects of anxiety sensitivity and distress intolerance on alcohol use frequency or quantity, cannabis use quantity, or cannabis problems. CONCLUSIONS: Anxiety sensitivity and distress intolerance share a common pathway to alcohol problems and cannabis use frequency through depressive symptoms. Interventions focused on modulating negative affectivity may reduce cannabis use frequency and alcohol problems.

Cannabis demand and use among veterans: A prospective examination.

OBJECTIVE: Cannabis demand (i.e., relative value), assessed cross-sectionally via a hypothetical marijuana purchase task (MPT), has been associated with use, problems, and dependence symptoms, among others. However, limited work exists on the prospective stability of the MPT. Furthermore, cannabis demand among veterans endorsing cannabis use, and the prospective cyclical relationship between demand and use over time, have yet to be investigated. METHOD: Two waves of data from a veteran sample (N = 133) reporting current (past 6-month) cannabis use were analyzed to assess stability in cannabis demand over 6 months. Autoregressive cross-lagged panel models (CLPMs) assessed the longitudinal associations between demand indices (i.e., intensity, Omax, Pmax, breakpoint) and cannabis use. RESULTS: Baseline cannabis use predicted greater intensity (ß = .32, p < .001), Omax (ß = .37, p < .001), breakpoint (ß = .28, p < .001), and Pmax (ß = .21, p = .017) at 6 months. Conversely, baseline intensity (ß = .14, p = .028), breakpoint (ß = .12, p = .038), and Pmax (ß = .12, p = .043), but not Omax, predicted greater use at 6 months. Only intensity demonstrated acceptable prospective reliability. CONCLUSIONS: Cannabis demand demonstrated stability over 6 months in CLPM models, varying along with natural changes in cannabis use. Importantly, intensity, Pmax, and breakpoint displayed bidirectional predictive associations with cannabis use, and the prospective pathway from use to demand was consistently stronger. Test-retest reliability ranged from good to poor across indices. Findings highlight the value of assessing cannabis demand longitudinally, particularly among clinical samples, to determine how demand fluctuates in response to experimental manipulation, intervention, and treatment. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

"I still partly think this is bullshit": A qualitative analysis of cannabinoid hyperemesis syndrome perceptions among people with chronic cannabis use and cyclic vomiting.

BACKGROUND: Cannabis is the most widely used psychoactive substance in the United States (US), with reported use patterns increasing among adults in recent years. Cannabinoid hyperemesis syndrome (CHS) has been one concern related to increased cannabis use patterns. US emergency departments have reported an increase of CHS cases over the last decade, yet little is known about CHS. This study explores the experiences of people with chronic cannabis use and cyclic vomiting and their perceptions of CHS. METHODS: Semi-structured interviews were conducted with 24 people recruited from a prospective cohort of patients presenting to Rhode Island emergency departments with symptomatic cyclic vomiting and chronic cannabis use. Data were analyzed thematically using NVivo. FINDINGS: Participants characterized their cyclic vomiting as related to food and alcohol consumption patterns, stress, and existing gastrointestinal issues. Despite recurrent episodes of cyclic vomiting, nausea, and abdominal pain, many participants remained uncertain whether their symptoms were driven by cannabis. Many participants relied on at-home research to assess their symptoms and seek out management approaches. Clinical treatment recommendations focused on cannabis cessation. However, most participants felt clinical recommendations failed to consider the complexity and challenge of stopping cannabis use given the chronicity of use and therapeutic benefits some perceived cannabis to have. CONCLUSIONS: Although cannabis cessation is the only reported CHS cure to date, additional clinical and non-clinical treatment approaches are needed to better support people with chronic cannabis use and cyclic vomiting to meet their ongoing needs.

Can I see some ID? Examining validity of the marijuana purchase task among late adolescent cannabis users.

Cannabis demand (i.e., reinforcing value) can be assessed using a marijuana purchase task (MPT; assesses hypothetical purchasing of cannabis at escalating prices) and has been related to use frequency, problems, and cannabis use disorder symptoms in adults. Cannabis demand has yet to be studied in adolescents, which can inform prevention and intervention efforts to reduce cannabis-related risks. The present study sought to validate the MPT with a sample of late adolescent lifetime cannabis users. Participants aged 15-18 years old (n = 115, Mage = 16.9, SD = 0.9) residing in a state with legalized cannabis use completed online assessments at baseline and 6-month follow-up. Convergent and divergent validity was examined, while principal component analysis was conducted to determine the factor structure and assess predictive validity. Three indices, Omax (i.e., maximum expenditure on cannabis), breakpoint (i.e., price suppressing consumption to zero), and alpha (i.e., degree to which consumption decreases with increasing price) were all significantly associated with cannabis use, consequences, craving, and expenditures and significantly differentiated low-risk users and high-risk users as measured by the Cannabis Use Disorders Identification Test-Revised (CUDIT-R). A two-factor solution reflecting amplitude (intensity, alpha, Omax) and persistence (breakpoint, Pmax) was observed. Both factors were associated with cannabis use and consequences in baseline regression models. At follow-up, persistence was associated with consequences; amplitude was not associated with either outcome. These findings provide initial evidence that the MPT is a valid measure for assessing cannabis demand among adolescents and can be used to understand mechanisms of adolescent cannabis use. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Concurrent validity of the marijuana purchase task: a meta-analysis of trait-level cannabis demand and cannabis involvement.

BACKGROUND AND AIMS: The Marijuana Purchase Task (MPT) is increasingly used to measure cannabis reinforcing value and has potential use for cannabis etiological and regulatory research. This meta-analysis sought to evaluate for the first time the MPT's concurrent validity in relation to cannabis involvement. METHODS: Electronic databases and pre-print repositories were searched for MPT studies that examined the cross-sectional relationship between frequency and quantity of cannabis use, problems, dependence, and five MPT indicators: intensity (i.e. unrestricted consumption), Omax (i.e. maximum consumption), Pmax (i.e. price at which demand becomes elastic), breakpoint (i.e. first price at which consumption ceases), and elasticity (i.e. sensitivity to rising costs). Random effects meta-analyses of cross-sectional effect sizes were conducted, with Q tests for examining differences by cannabis variables, meta-regression to test quantitative moderators, and publication bias assessment. Moderators included sex, number of MPT prices, variable transformations, and year of publication. Populations included community and clinical samples. RESULTS: The searches yielded 14 studies (n = 4077, median % females: 44.8%: weighted average age = 29.08 [SD = 6.82]), published between 2015 and 2022. Intensity, Omax , and elasticity showed the most robust concurrent validity (|r's| = 0.147-325, ps < 0.014) with the largest significant effect sizes for quantity (|r| intensity = 0.325) and cannabis dependence (|r| Omax = 0.320, |r| intensity = 0.305, |r| elasticity = 0.303). Higher proportion of males was associated with increased estimates for elasticity-quantity and Pmax -problems. Higher number of MPT prices significantly altered magnitude of effects sizes for Pmax and problems, suggesting biased estimations if excessively low prices are considered. Methodological quality was generally good, and minimal evidence of publication bias was observed. CONCLUSIONS: The marijuana purchase task presents adequate concurrent validity to measure cannabis demand, most robustly for intensity, Omax , and elasticity. Moderating effects by sex suggest potentially meaningful sex differences in the reinforcing value of cannabis.

Prospective associations between sleep disturbances and cannabis use among Veterans: A behavioral economic approach.

BACKGROUND: Veterans often use cannabis for sleep despite limited evidence of its efficacy. Moreover, how sleep disturbances impact cannabis use longitudinally is unclear. We applied a behavioral economic framework to examine whether sleep disturbances and cannabis demand (i.e., relative value) were related risk-factors for future cannabis use and problems. METHODS: Veterans deployed post-9/11/2001 who reported past 6-month cannabis use at baseline (n = 126) completed surveys on their sleep disturbances, demand via the Marijuana Purchase Task (MPT), and cannabis use. Mediation analyses using Hayes' PROCESS Macro and zero-inflated negative binomial models tested indirect effects of baseline sleep disturbances on 12-month cannabis use frequency, quantity, and problems via 6-month cannabis demand (i.e., intensity, Omax, Pmax, and breakpoint). RESULTS: Only Omax (i.e., maximum expenditure for cannabis) was a significant mediator for 12-month cannabis use quantity and problems when examined concurrently with other demand indices after controlling for covariates. Intensity (i.e., purchase at zero cost) was a significant mediator for 12-month cannabis use frequency when examined concurrently with other demand indices in models controlling for lifetime cannabis use, but not past 30-day use at baseline. CONCLUSION: Cannabis demand, specifically intensity and Omax, may help to identify Veterans with sleep disturbances who are at increased risk for escalating their cannabis use. Subsequent research should assess the extent that sleep disturbances impact cannabis demand in the context of withdrawal, which will inform novel prevention and intervention strategies geared toward reducing negative cannabis-related outcomes among Veterans.

The anticipated effects of simultaneous alcohol and cannabis use: Initial development and preliminary validation.

Social learning theories suggest that outcome expectancies are strong determinants of behavior, and studies find that alcohol and cannabis expectancies are associated with negative substance use outcomes. However, there are no measures to date that assess expectancies for simultaneous alcohol and cannabis use (SAM), often referred to as SAM, despite strong links with negative consequences and rising time trends. The present study sought to provide initial validation of test scores for the Anticipated Effects of Simultaneous Alcohol and Cannabis Use Scale (AE-SAM), using a sample of past month college student simultaneous users (N = 434). Exploratory factor analysis and confirmatory factor analysis conducted in random half samples suggested five expectancy factors, representing high arousal positive, high arousal negative (alcohol driven), high arousal negative (cannabis driven), low arousal positive, and low arousal negative expectancies. The factor structure was invariant across sex, race/ethnicity, and simultaneous use frequency, and demonstrated convergent and discriminant validity with other alcohol/cannabis expectancy measures. AE-SAM high arousal positive expectancies were associated with simultaneous use frequency and heavier drinking/cannabis use, AE-SAM high arousal negative (cannabis driven) expectancies were associated with less frequent simultaneous use and more negative alcohol consequences, and AE-SAM low arousal negative expectancies were associated with less cannabis use. Effects of AE-SAM high arousal positive and high arousal negative (cannabis driven) expectancies remained, above and beyond other expectancy measures, suggesting that AE-SAM expectancies provide additional information beyond single substance expectancies. The results demonstrate the feasibility and utility of assessing simultaneous use expectancies, and lay groundwork for future research on simultaneous use expectancies in relation to alcohol and cannabis couse outcomes. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Longitudinal associations between impulsivity and alcohol and cannabis use frequency, quantity, and problems among military veterans.

OBJECTIVE: Impulsivity is an established etiological risk factor for alcohol- and cannabis-related outcomes. However, limited work has focused on longitudinal associations between multiple trait impulsivity facets and indices of alcohol and cannabis use among military veterans-a contextually distinct population that evidence unique impulsive personality traits and substance use patterns. METHOD: A structural equation model (SEM) examined longitudinal associations between five UPPS-P impulsivity facets measured at baseline and six indices of alcohol and cannabis use (i.e., frequency, quantity, and problems) measured at 1-year follow-up among 361 returning Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn (OEF/OIF/OND) veterans. RESULTS: Findings indicated baseline sensation seeking was significantly positively associated with 1-year alcohol use frequency (ß = .18); baseline negative urgency was positively associated with alcohol use problems (ß = .31); and baseline lack of perseverance (ß = .25) and sensation seeking (ß = .21) were positively associated with 1-year cannabis use problems. None of the baseline impulsivity facets were associated with 1-year alcohol use quantity, cannabis use frequency, or cannabis use quantity. CONCLUSIONS: Results provide preliminary support that impulsivity may play a unique role in understanding alcohol- and cannabis-related problems over time among veterans. Further, results suggest that specific impulsivity facets are prospectively associated with cannabis problems (i.e., lack of perseverance and sensation seeking) and alcohol problems (i.e., negative urgency). Findings reinforce the importance of differentially evaluating impulsivity-substance use associations within contextually distinct populations (e.g., adolescent, veteran), and highlight potentially meaningful intervention targets among veterans. However, replication is needed with stronger temporal controls and more diverse veteran subsamples. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Patterns of Cannabis and Alcohol Co-Use: Substitution Versus Complementary Effects.

PURPOSE: The purpose of this review is to discuss the literature regarding the concurrent use (co-use) of alcohol and cannabis and competing hypotheses as to whether cannabis acts as a substitute for (i.e., replacing the effects of alcohol, resulting in decreased use) or a complement to (i.e., used to enhance the effects of alcohol, resulting in increased use) alcohol. The impact of cannabis use on alcohol-related outcomes has received increased attention in the wake of ongoing legalization of cannabis for both medical and recreational purposes. Evidence for both hypotheses exists in the literature across a broad range of data collection methods and samples and is carefully reviewed here. In addition, various mechanisms by which cannabis may act as an alcohol substitute or complement are explored in depth with the goal of better understanding equivocal findings. SEARCH METHODS: This review includes articles that were identified from a search for studies on alcohol and cannabis co-use, with a specific focus on studies exploring complementary versus substitution aspects of co-use. Search terms were included in Google Scholar, PsycINFO, MEDLINE, and Web of Science. Eligible studies were those that measured alcohol and cannabis co-use in human samples in laboratory, survey, or ecological momentary assessment studies, or that directly referenced substitution or complementary patterns of use. SEARCH RESULTS: Search results returned 650 articles, with 95 meeting inclusion criteria. DISCUSSION AND CONCLUSIONS: Results of this review reveal compelling evidence for both substitution and complementary effects, suggesting nuanced yet significant distinctions across different populations examined in these studies. Several mechanisms for the impact of cannabis use on alcohol-related outcomes are identified, including patterns and context of co-use, timing and order of use, cannabinoid formulation, pharmacokinetic interactions, and user characteristics (including diagnostic status), all of which may influence substitution versus complementary effects. This review will inform future research studies examining this topic in both clinical and community samples and aid in the development of treatment and prevention efforts targeting those populations most vulnerable to negative consequences of co-use. Finally, this review highlights the need for additional research in more diverse samples and the use of mixed-methods designs to examine both pharmacological and contextual influences on co-use.

Cannabis use and posttraumatic stress disorder: prospective evidence from a longitudinal study of veterans.

BACKGROUND: Posttraumatic stress disorder (PTSD) is the most highly co-occurring psychiatric disorder among veterans with cannabis use disorder (CUD). Despite some evidence that cannabis use prospectively exacerbates the course of PTSD, which in turn increases the risk for CUD, the causal nature of the relationship between cannabis and psychiatric comorbidity is debated. The longitudinal relationship between PTSD diagnosis and traumatic intrusion symptoms with cannabis use and CUD was examined using cross-lagged panel model (CLPM) analysis. METHODS: Prospective data from a longitudinal observational study of 361 veterans deployed post-9/11/2001 included PTSD and CUD diagnoses, cannabis use, and PTSD-related traumatic intrusion symptoms from the Inventory of Depression and Anxiety Symptoms. RESULTS: A random intercept CLPM analysis that leveraged three waves (baseline, 6 months and 12 months) of cannabis use and PTSD-related intrusion symptoms to account for between-person differences found that baseline cannabis use was significantly positively associated with 6-month intrusion symptoms; the converse association was significant but reduced in magnitude (baseline use to 6-month intrusions: ß = 0.46, 95% CI 0.155-0.765; baseline intrusions to 6-month use: ß = 0.22, 95% CI -0.003 to 0.444). Results from the two-wave CLPM reveal a significant effect from baseline PTSD to 12-month CUD (ß = 0.15, 95% CI 0.028-0.272) but not from baseline CUD to 12-month PTSD (ß = 0.12, 95% CI -0.022 to 0.262). CONCLUSIONS: Strong prospective associations capturing within-person changes suggest that cannabis use is linked with greater severity of trauma-related intrusion symptoms over time. A strong person-level directional association between PTSD and CUD was evident. Findings have significant clinical implications for the long-term effects of cannabis use among individuals with PTSD.

The Potential Impact of Legalization of Recreational Cannabis among Current Users: A Qualitative Inquiry.

Given legislative initiatives in Rhode Island pertaining to consideration of cannabis legalization for recreational purpose, a qualitative inquiry was conducted regarding anticipated changes in use among recreational cannabis users in Rhode Island. Five focus groups were conducted with recreational cannabis users (N = 31; 6-7 per group). Participants were queried about anticipated impact of legalization on their use patterns. Themes were identified using applied thematic analysis. Participants discussed (1) a desire to maintain the status quo due to satisfaction with local cannabis regulations and their current use behaviors, (2) how and why cannabis use may change, including pros and cons of legalization, and (3) anticipated changes in purchasing behavior given display and legitimacy of legal dispensaries. While participants anticipate use levels and prevalence may remain relatively stable following legislation changes, findings suggest possible changes related to mode of administration and location of use. Public health concerns exist related to high-risk potencies and use of cannabis in edible form; therefore, trialing of new cannabis products has important clinical implications should legalization occur in Rhode Island.

Drinking less on cannabis use days: The moderating role of UPPS-P impulsive personality traits.

Objective: Several studies suggest that alcohol and cannabis co-users are heavier drinkers and experience more alcohol-related consequences. However, day-level associations between co-use and drinking levels are mixed. One reason may be that individual characteristics moderate the daily impact of using alcohol alone or in conjunction with cannabis. The theory would suggest that highly impulsive individuals may drink more on co-use days, yet this assertion remains untested. Therefore, the current study tested whether impulsivity moderated the effect of co-use on same-day drinking quantity within veterans, a high-risk sample for substance use and impulsivity. Method: In a longitudinal observational study, co-using veterans (N = 139) completed three semi-annual assessments reporting on their daily drinking quantity and cannabis use via Timeline Followback (Observations = 19,245) and impulsivity via the UPPS-P. Mixed effect modeling was used to test hypotheses that co-use (compared to alcohol-only) days would be associated with heavier drinking for those high (but not low) in positive and negative urgency. Results: Significant interactions were found for positive urgency (PU) and lack of perseverance (LP), such that individuals at mean and low levels of PU and LP drank less on co-use (compared to alcohol-only) days. There were no significant interactions for other UPPS-P impulsivity facets. Conclusion: Findings are consistent with a substitution/compensatory effect for individuals at mean and low levels of both UPPS-P facets, and may be a byproduct of frequent cannabis use in veterans. In contrast, findings suggest that co-use and alcohol-only days may be characterized by similarly high levels of drinking for highly impulsive individuals. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Protocol for the Project SAVE randomised controlled trial examining CBT for insomnia among veterans in treatment for alcohol use disorder.

INTRODUCTION: As many as 74% of veterans with alcohol use disorders (AUDS) report symptoms of insomnia. Insomnia represents a barrier to alcohol treatment because insomnia symptoms (1) may lead to relapse among those who use alcohol to help them sleep and may negatively impact (2) executive functions and (3) emotion regulation skills. Cognitive-behavioural therapy for insomnia (CBT-I) is an efficacious first-line treatment for insomnia; however, no research has examined the impact of CBT-I on individuals' response to alcohol treatment. In the Sleep and Alcohol for Veterans (Project SAVE) randomised controlled trial, we hypothesise that CBT-I will enhance the efficacy of alcohol treatment among Veterans with insomnia by enhancing their abilities to attend to treatment, regulate emotions and initiate sleep without alcohol. METHODS AND ANALYSIS: Eighty Veterans enrolled in alcohol treatment at the Veterans Administration (VA) hospital will be randomly assigned to receive either CBT-I or single-session sleep hygiene (SH) education. Individuals will be eligible to participate if they meet Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for moderate to severe AUD and Insomnia Disorder of at least 1-month duration. Participants will complete assessments at baseline, post-treatment and 6-week follow-up. Preliminary process outcomes include retention/recruitment rates and treatment satisfaction (feasibility and acceptability, respectively). Primary outcomes are insomnia severity, percentage of heavy-drinking days and alcohol-related problems. We will assess a variety of secondary clinical and mechanistic outcomes (eg, post-traumatic stress disorder (PTSD) symptoms, attention and working memory). ETHICS AND DISSEMINATION: Ethics approval was obtained in October 2018. Data collection began in July 2019 and is planned for completion by July 2021. Trial results will be disseminated at local and national conferences, in peer-reviewed publications and through media outlets, as available. Results will also be shared with interested participants and clinical collaborators at the end of the trial. TRIAL REGISTRATION NUMBER: clinicaltrials.gov identifier NCT03806491 (pre-results).