Gaps in Identification, Referral and Treatment of Cannabis Use in VA Primary Care

背景：大麻使用和大麻使用障碍（CUD）在美国人口中正在增加， 50岁及50岁以上的人是大麻使用者中增长最快的群体。虽然大麻的使用在增加， 它通常被认为是无害的，并被销售给患者，作为对几种情况有帮助的产品，尽管缺乏 证据没有关于过去一个月大麻使用，每日大麻使用和退伍军人使用CUD的数据 初级保健，但有证据表明，大麻的使用是常见的特定退伍军人亚组（11%至25%） 并且使用管理数据识别的CUD正在增加。 重要性：有理由对大麻使用的潜在识别不足感到担忧 在退伍军人中。吸食大麻是退伍军人中最常见的大麻使用形式， 有证据表明，大麻使用与呼吸道症状和癌症有关。共病心理健康 条件是普遍的退伍军人，这些条件通常被报告为动机， 经常吸食大麻大麻的使用对患有焦虑症的退伍军人的治疗结果产生负面影响， 抑郁症和创伤后应激障碍（PTSD），使用与精神病和自杀有关 构思能力大麻戒断症状经常与精神健康症状相混淆 患者可能会长期使用。最后，有有效的行为治疗方法可用于 CUD和几种药物在治疗CUD和大麻戒断中显示出益处， 审判必须查明大麻使用者，以确保获得有效的治疗。 创新和影响：该提案将解决妇女健康优先领域的重大差距， 物质使用障碍和心理健康。这一建议将为验证一个简单的， 在初级保健环境中可行的基于频率的大麻使用筛查措施。 具体目标：我们建议提高我们对高危人群的认识，并确定 退伍军人中的大麻治疗服务未得到充分利用。我们还建议确定， 某些使用模式与不利的精神和身体健康结果有关， 更高的风险。这些人（如果确定）也可能需要短暂的干预，转诊和/或治疗。 目标1：审查大麻使用模式（过去一个月使用、每日使用、CUD、持续使用）， 行为（例如，酒精使用）与使用相关，以及与全国范围内使用相关的特征 接受VA初级保健的50岁及以上退伍军人的代表性样本。 目标2a：确定退伍军人是否与其提供者讨论大麻使用，以及提供者是否 记录使用和/或干预使用或CUD。 目标2b：探索提供者评估大麻使用和启动CUD相关治疗的经验 以及初级保健机构的转诊。 目标3：使用目标1中创建的队列，我们将前瞻性地研究大麻使用的相关性。 抑郁症，焦虑症，创伤后应激障碍，失眠症，急诊室使用，和全因住院。 方法：我们将使用VA数据构建一个具有全国代表性的50岁及以上退伍军人队列， 病历审查和电话采访我们将与初级保健提供者进行定性访谈， 了解护理中的差距。 下一步/实施：与酒精和烟草一样，可以有效监测大麻的定期使用 并通过识别和短暂干预进行管理。这一建议将增进我们对 未查明的大麻使用流行率和初级保健环境中的护理差距，筛查的必要性， 并提高我们对与使用相关的危害的理解。这项提案将为以下方面奠定基础： 解决老年退伍军人中与大麻使用和CUD有关的护理差距。

Background: Cannabis use and cannabis use disorder (CUD) are increasing in the US population, and adults aged 50 and older are among the fastest growing groups of cannabis users. While cannabis use is increasing, it is often perceived as harmless and marketed to patients as helpful for several conditions despite a lack of evidence. There is no data on past month cannabis use, daily cannabis use, and CUD among Veterans using primary care, but there is evidence that cannabis use is common in specific Veteran subgroups (11% to 25%) and that CUD identified using administrative data is increasing. Significance: There are reasons to be concerned about the potential under-identification of cannabis use among Veterans. Smoking cannabis is the most common form of cannabis use among Veterans, and there is evidence that cannabis use is associated with respiratory symptoms and cancer. Comorbid mental health conditions are prevalent among Veterans, and these conditions are commonly reported as motivation for regular cannabis use. Cannabis use negatively impacts treatment outcomes of Veterans with anxiety, depression, and post-traumatic stress disorder (PTSD), and use is associated with psychosis and suicidal ideation. Symptoms of cannabis withdrawal can frequently be confused with symptoms of mental health conditions by patients which can perpetuate use. Finally, there are effective behavioral treatments available for CUD and several medications that have shown benefit in treatment of CUD and withdrawal from cannabis in trials. It is important to identify cannabis users to ensure access to effective therapies. Innovation and Impact: This proposal will address important gaps in the priority areas of women’s health, substance use disorders, and mental health. This proposal will lay the foundation for the validation of a simple, frequency-based screening measure for cannabis use that could be feasible in the primary care setting. Specific Aims: We propose to improve our understanding of at-risk populations and determine whether cannabis treatment services in the Veteran population are being underused. We also propose to determine if certain use patterns are associated with adverse mental and physical health outcomes, placing individuals at higher risk. Such individuals (if identified) may also require brief intervention, referral, and/or treatment. Aim 1: To examine the patterns of cannabis use (past month use, daily use, CUD, persistent use), behaviors (e.g., alcohol use) associated with use, and characteristics associated with use among a nationally representative sample of Veterans 50 and older who receive VA primary care. Aim 2a: To determine whether Veterans discuss cannabis use with their providers and whether providers document use and/or intervene upon use or CUD. Aim 2b: To explore provider experiences assessing cannabis use and initiating CUD-related treatment and referrals in the primary care setting. Aim 3: Using the cohort created in Aim 1, we will prospectively examine the association of cannabis use with depression, anxiety, PTSD, insomnia, emergency department use, and all-cause hospitalization. Methodology: We will construct a nationally representative cohort of Veterans 50 and older using VA data, chart review and phone interviews. We will conduct qualitative interviews with primary care providers to understand gaps in care. Next Steps/Implementation: As with alcohol and tobacco, regular cannabis use may be effectively monitored and managed with identification and brief intervention. This proposal will improve our understanding of the prevalence of unidentified cannabis use and gaps in care in the primary care setting, the need for screening, and improve our understanding of the harms associated with use. This proposal will lay the foundation for addressing gaps in care related to cannabis use and CUD among older Veterans.