iCount for Veterans: A Research Platform to Connect Veterans with Cannabis Research Studies Led by the Cannabis Center of Excellence, UMass Dartmouth, and Patriots Helping Vets

According to the US Census Bureau data, as of 2020, there are about 19 million veterans aged 18 and older in the United States, with more than 34% of those veterans using the US Department of Veterans Affairs (VA) for healthcare (1). US military service members and veterans often face different health issues than civilians because they are at risk for various injuries during their services. These injuries can happen during combat, while others involve physical stress to the body due to exposure to environmental hazards such as contaminated water, chemicals, infections, and burn pits—many of these injuries are life-threatening or can cause long-term disability (2). In addition, service members are also disproportionally at risk of developing a variety of mental health problems, including anxiety, post-traumatic stress disorder (PTSD), depression, substance use disorder (SUD), and suicide (2). Veterans may encounter a variety of stress-related disorders and challenges when reintegrating from the military into the community. Enabling veterans’ reintegration, readjustment, transition, coping, and community integration is a societal emphasis.

Every year more than 200,000 veterans transition out of service, and research suggests that supporting veterans in the early transition period is essential considering the readjustment challenges (3). Vogt and colleagues piloted a five-year study with a nationally representative sample of more than 9000 US veterans. This study was the first to explore how the US veteran population’s health and broader well-being (that is, work and social relationships) change in the first several years after they leave military service. The study found that veterans experienced decreases in health and well-being over the three years of the study—health concerns were the top cases, where many veterans reported having chronic physical (53%) or mental (33%) health conditions. The most significant conditions conveyed included: chronic pain, sleep problems, anxiety, and depression (4).

Chronic pain is more prevalent and eminent in veterans than in the general population (5). During 2019, veterans aged ≥20 years were more likely to have chronic pain than non-veterans (31.5% versus 20.1%), and among veterans, those aged 50–64 years had the highest prevalence of chronic pain (37.2%) (6). In addition, as the COVID-19 pandemic heightened so did the incidence and severity of mental health problems and substance use disorders in 2020—about 17 veterans committed suicide daily (7). Indeed, recent data point that among veterans committing suicide in 2020, about 1 in 3 suffered from depression, 1 in 4 suffered from anxiety, 1 in 5 suffered from alcohol use disorder, 1 in 4 had PTSD, and nearly 1 in 12 suffered from opioid use disorder (8).

The resulting and compounding health circumstances veterans meet post-deployment come with the demand for healthcare, numerous prescription medications, mental health interventions, and alternative treatments. A study conducted in 2020 of 1700 US Iraq and Afghanistan veterans discovered that 46% were prescribed anti-depressants, 36% sleeping pills, 35% anti-anxiety medications, and 32% opioids (9). Another survey led by the Defense Department uncovered that about one in four veterans had at least one opioid prescription in 2017, yet only one-tenth (0.001%) of them were obtaining care for a diagnosed opioid use disorder (10).

Increasing opioid dosing does not appear to improve chronic pain. A study by VA Portland researchers in 2020 noted that out of 500 patients with chronic pain, nearly 20% had their opioid dose increased, although solely 3% of those patients indicated meaningful progress in pain (5). Medical cannabis may offer a practical and low-risk treatment alternative for veterans, primarily when compared to conventional treatments (for example, alcohol, medications, and opioids) for health conditions, including PTSD (11). Expanding access to medical cannabis as an alternative to opiates and other prescription painkillers for the relief of chronic pain has the potential to help veterans relieve substance use disorders and increase their well-being (12).

Based on our research and findings in the studies described above, we set out to conduct an iCount for Veterans’ study to discover how medical cannabis was helping veterans in Massachusetts and nationally. iCount for Veterans is a partnership with Patriots Helping Vets, University of Massachusetts (UMass) Dartmouth, and the Cannabis Center of Excellence (CCOE) to expand access to cannabis for veterans and conduct real-world studies on its impact on health and wellness. This study is approved by the UMass Dartmouth Institutional Review Board (IRB), and the surveys and ongoing engagement with veterans as part of this study will be deployed and managed through iCount, a platform hosted by the CCOE. Study partners contribute cannabis for veterans’ research and access, depending on the unique research project.

Project partners provide the products or other offers to veterans and deliver the cannabis to the retail outlets in Massachusetts. Other project partners provide study products that are available nationally to veterans. The CCOE and Patriots Helping Vets will conduct research studies using the cannabis products to be sold to veterans through retail cannabis dispensaries in different parts of Massachusetts. Supported by Patriots Helping Vets to recruit veterans to participate, the CCOE facilitates the data collection (that is, basic demographics, self-reported health and wellness, and side effects of using cannabis) from veterans who get the cannabis and report for the research studies.

Veterans will be required to register to be part of the studies through a CCOE sign-up. They will receive a code to be presented at the participating Massachusetts cannabis retail outlets to confirm their status as a study participant. Here we report on some studies conducted through iCount for Veterans.

iCount for Veterans Intake Survey

Key Findings

Recently, 368 veterans signed up for iCount for Veterans, and 232 have completed the iCount for Veterans intake survey. This survey enrolls veterans to be a part of the iCount for Veterans program, where veterans can participate in future studies without completing other intake questions.

• In terms of health conditions veterans were experiencing (N=193), 75% reported depression/mood as the top health condition, followed by anxiety (74%), PTSD (63%), and chronic and severe pain (48%). Cannabis was most helpful for chronic pain (25.4%) and depression/mood (20%) for these respondents.
• Among all veterans who responded (N=124), more than 26% rated anxiety as a symptom that is primarily associated with their primary health conditions, followed by depression (19.6%), sleep (12.6%), and pain (22.5%). Chronic and severe pain, depression/mood (20%), and anxiety (17.7%) were the primary health conditions for which the veterans found cannabis to be the most practical.
• About 52.3% (N=130) of respondents were actively trying to lower medication use with cannabis. Veterans were also asked to identify all medications they attempted to drop by consuming cannabis. Overall (N=68), 47% of veterans reported trying to reduce antidepressants, 41% over-the-counter (OTC) medications, 26% mood stabilizers or anticonvulsants, and 22% muscle relaxants.
• Regarding monthly out-of-pocket spending on cannabis versus medications, around 63% of veterans (N=82) spent US $0–17 on medications, whereas about 23% reported paying US $142–233 on cannabis (N=179). More than 85% of veterans who responded are covered by health insurance, and about 93% have prescription drug coverage.
• Among veterans who responded (N=230), dispensary agents were the most notable place to get informed to make decisions about cannabis products (44%), followed by mobile apps and websites (42%), Google search (32%), and friends (31%).

Undoo Study

About the Study

Undoo softgels are an emergency supplement intended to clear your head and ease the intensity of the cannabis buzz in a short period of time. It does not eliminate the feeling of well-being often experienced with tetrahydrocannabinol (THC). The Undoo softgels formula has multiple uses including but not limited to: manage THC overconsumption and used to swiftly clear the consumer’s head from accidental overindulgence, to clear “brain fog” from residual consumption issues, and a “reset THC tolerance” for experienced cannabis consumers.

The CCOE is conducting a research study to assess the impact of Undoo on up to 500 veterans in the US. The research study launched nationally for US military veterans in August 2022. To be a study participant, veterans are required to visit the CCOE website and iCount for Veterans to get verified and enrolled. Veterans who enroll will receive Undoo packets as part of their participation and will be mailed the product (each package contains 30 soft gels) by the CCOE. After receiving the product, veterans will report its effectiveness for the intended outcomes. As of December 2022, 308 veterans have signed up for the Undoo study.

Undoo Use Cases

Veterans will be able to test out three Undoo products.

1. Reset THC tolerance

Frequent cannabis consumers and patients can experience a THC tolerance build up or diminished effects of their cannabis products. With Undoo Reset, consumers can restore their THC tolerance. Suggested use: participants must take 2 softgels (75 mg of olivetol per softgel) with 12–16 oz of water before bed for five consecutive nights and take no more than 6 softgels in a 24-hour period.

2. THC Overconsumption

Whether someone is a new or experienced cannabis consumer, at times, THC can have unpredictable psychoactive effects, leaving them in an uncomfortable dysphoria. Undoo Rescue softgels can help clear their head and bring them to a more enjoyable state. Suggested use for participants:

• Take 2 (60 mg of olivetol per softgel) softgels with 12–16 oz of water
• Relax - relief is typically felt within 5–20 minutes
• Take no more than 8 softgels in a 24-hour period

3. Brain Fog

Lingering haziness from cannabis consumption can leave someone in a mental fog. Undoo Refresh softgels promotes clarity to bring someone to a more comfortable state. Suggested use for participants:

• Take 1 softgel (60 mg of olivetol per softgel) with 12–16 oz of water
• Extra foggy? Double up with 2 softgels
• Take no more than 8 softgels in a 24-hour period

Undoo Preliminary Result

Three Online Undoo Surveys

Undoo Rescue, Reset, and Refresh are available for people who have taken the products to self-report an assessment of each product’s impacts on intended outcomes. The surveys are available by QR codes or mobile or computer data entry links. Live data dashboards will be available for the project team to monitor real-time results. Veterans can also report a testimonial in their own words with the study for use with Undoo marketing.

The same six veterans completed the Undoo Rescue and Refresh survey about the time needed for both products to work. Two veterans reported that the rescue package started to kick in within 10 minutes after consumption, and most of those who took the refresh packet (2 veterans) felt the effects within 20 minutes (Figure 1). On the other hand, among veterans who responded to the Undoo Reset survey (N=11), about 45%, 18%, and 36%, respectively, rated as moderately, very, and highly tolerant of cannabis. More than 50% of those who responded were in a moderate need for a tolerance break (Figure 2).

Of those who responded to the Rescue study (N=6), about 83% reported that they would either reuse the product or recommend it to others. Around 67% felt that the Rescue product addressed their cannabis overconsumption, whereas the product was swift for 50% of the respondents. Please see Figure 3 for additional data.

In terms of feelings after taking each of the Undoo products, six respondents felt that the Undoo Refresh package successfully overcame their brain fog. More veterans also reported being more comfortable driving (8), operating heavy machinery (6), doing complex tasks (6), and talking with some authority figures (5), particularly after taking the Rescue and Refresh product (Figure 5). Authority figures that veterans would have been comfortable talking with before and after ingesting each Undoo product were about the same (Figure 6).

Veterans were also asked to identify other feelings (in addition to the above) that they found the packages helpful. Overall, more veterans (about a 50% increase) felt calm, cool, comfortable, and liked the effects they were experiencing after taking the products. The range of psychologically bad feelings also decreased dramatically after taking the products, and more veterans felt lively after taking the Rescue (2), Reset (2), and Refresh (2) packages. Regarding the Rescue package, most respondents reported anxiety (29%) and fatigue (29%) before consumption. However, confident, competent, and energetic became the most reported feelings after taking the product. Please see Figures 7–9 for additional details.

Among other feelings veterans reported having, mental clarity (40%), increased energy (40%), and decreased bruxism (20%) were the only feelings that appeared after taking the Undoo Rescue package. After consuming the Refresh product, these three feelings also become the most noted by veterans. Anxiety, dry mouth, and toughness to get started in the morning became the only existing veterans’ sensations after taking the Undoo Reset package (notice Figures 10 and 11 for additional data).

The US military veterans in our Undoo research study noted the effectiveness of three Undoo products in diverse intended conditions, including time to kick in, tolerance levels, and distinct physical and psychological effects following the consumption. In general, veterans reported that using Undoo products significantly enhanced their physical and mental health conditions. Most veterans will likely use the products again or suggest the products to someone else. Barriers to using the products include anxiety and dry mouth after taking the products and concern about possible side effects following cannabis consumption in the future. Further research with more samples and rigorous study designs will help better identify the results of the three Undoo products on various health conditions veterans face.

Gibby’s Garden Study

The CCOE, Gibby’s Garden, and Patriots Helping Vets established a cannabis access research project for veterans using Gibby’s Garden cannabis products to be offered at low cost to the first 450 qualifying veterans through four retail cannabis dispensaries in different parts of Massachusetts (MA): The Vault, Boston Bud Factory, South Shore Buds, and Seagrass Salem Dispensary.

The project was initiated in April 2022 and will be concluded in December 2022. Gibby’s Garden will donate products, designate the number of products and how the products will be packaged for veterans, and deliver the product to the retail outlets. The CCOE will enable the data collection and report from veterans who get cannabis for the study. The CCOE also partners with Patriots Helping Vets to recruit veterans for free or low-cost cannabis and report on health and clinical metrics about the impact on veterans’ health conditions and symptoms. Currently, 157 veterans have signed up for the study and 111 opted to report the impact of the cannabis using Tetragram, a mobile application (app) for patients to report the impact of their cannabis use and track usage over time.

Registration Steps

1.  Qualifying veterans register for iCount for Veterans and take the CCOE Intake survey. They then select the cannabis dispensary they would like to purchase cannabis from in Massachusetts.
2. Veteran receives an email from the CCOE with information about the study, including a study code to present at the four retailers.
3. Veterans purchase cannabis from one of the four retail outlets in MA by presenting an email or screenshot of the study enrollment, along with their military ID, to qualify for the program.
4. Veteran reports on the impact of cannabis use on paper or using the Tetragram app to record the effects after each use.

The ideal minimum for each veteran is one-eighth of cannabis. Each package is tagged with a study number and packets come with a certificate of analysis (COA). The analysis will be matched with veterans who received the code upon registration with the CCOE for the study. Veterans can buy a package of products at a steeply reduced study rate at one of the four licensed cannabis retail dispensaries. The bundle includes the following:

• Two ⅛ ounces of cannabis flower
• 2 strains of pre-rolls
• 15 mL of cannabis tincture

The surveys and ongoing engagement with veterans as part of this study are deployed and managed through iCount for Veterans. The study will not demand veterans to fill in any personal identifying information. Still, it will collect basic demographics, self-reported health and wellness, product type, consumption methods, side effects of using the product, and a general overview of the product and their experience. Veterans will be requested to fill out the paper survey or log back into the Tetragram app for feedback each time they use the product and will receive the study results when it is concluded.

Among all veterans, 19 veterans have reported the impact of Gibby’s products using the Tetragram app. The most common reasons reported for consuming Gibby’s Garden cannabis products include: anxiety, joint pain, injury pain, depression, muscle pain, nerve pain, muscle spasms, agitation, headache, and insomnia. Overall, 46% of respondents rate Gibby’s Garden products a 5 out of 5 stars, and 39% rate them a 4 out of 5 stars.

Good Chemistry

In addition, Good Chemistry, the CCOE, and Patriots Helping Vets launched a veterans cannabis access research project in Massachusetts for qualifying veterans. Veterans can purchase products from Worcester, MA or Lynn, MA for special study pricing and share their feedback on the products! As part of the research study, veterans will be asked to report on access to cannabis issues, the products, and its impact on their health and wellness. This research study is approved by the UMass Dartmouth IRB. The bundle includes:

1. Day and night pre-roll pack: 1 sativa pre-roll and 1 indica pre-roll purchased at a steeply reduced study rate (select strains with focus on Amnesia Haze and Ingrid)
2. Mini joint packs: 4 each 1/2-gram pre-rolls purchased at a steeply reduced study rate (select strains with options for sativa and indica)

Once veterans purchase the bundle, we ask them to report its impact either using a paper form and returning it to Good Chemistry in an anonymous box (anon box) or using the Tetragram app. The surveys can help gauge the representativeness of individual views and experiences. The surveys focused on asking veterans’ responses on symptoms, consumption method, product type, specific consumption method (that is, joint, pipe, tincture, vaporizer, vape pen, and bong), and the overall review about their experience with the products. The result of this newly started survey will be discussed at the end of the study as critical evidence for cannabis decision-making moving forward.

Vape Survey

Vaping (using an electronic vaporizer) is a reasonably new behavior that has spread among the world’s cannabis smokers. The appeal of vaping lies in lowered harm and cost while keeping a sufficiently similar or superior experience to the established cannabis smoking.

The CCOE, UMass Dartmouth, and Green Lion Partners launched a new online veterans vape survey on November 11, 2022. Veterans will be required to register through the CCOE iCount sign up to be part of the study. The survey would take 5 minutes, and the first five veterans to sign up for the survey will receive a free vape device to evaluate.

This newly conducted vape survey will further inform the development of new vaping devices and the standardization of quality and safety testing protocols designed for today’s complex cannabis vape devices.

The Cannabis Vape Survey collects data from veterans’ cannabis consumers in MA and will provide valuable insights surrounding vaping devices currently available. In the upcoming months, we will conclude the study and provide insights about veterans’ “real-world” vaping experience.

How to Get Involved

The landscape of medical cannabis is rapidly expanding as more and more people push for its legalization. As the acceptance and usage of cannabis continue to grow in the United States, the demand for a further complete understanding of cannabis and its effects on human health and well-being is required.

We invite individuals and companies to participate in this continuing cannabis for veterans’ research study with the CCOE and partners. We are accepting donations and new research study partners for the iCount for Veterans project. Be sure to ask us if anything is unclear or you want more information. Thank you for taking the time to read this report.

• Veterans can sign up at: https://www.cannacenterofexcellence.org/veterans
• Companies can sign up at: www.cannacenterofexcellence.org/signup

References

1. The U.S. Census Bureau. https://www.census.gov/newsroom/press-kits/2021/acs-5-year.html (Accessed November 28, 2022)
2. MedlinePlus. https://medlineplus.gov/veteransandmilitaryhealth.html(Accessed November 28, 2022)
3. The U.S. Department of Veterans Affairs. https://www.research.va.gov/currents/0120-Health-ranks-as-top-concern-for-Veterans.cfm (Accessed November 28, 2022).
4. D.S. Vogt, et al., Am. J. Prev. Med., 58(3), 352–360 (2020). doi: 10.1016/j.amepre.2019.10.016.
5. The U.S. Department of Veterans Affairs. 2020. VA Research on Pain Management. https://www.research.va.gov/pubs/docs/va_factsheets/Pain.pdf (Accessed November 28, 2022).
6. The U.S. Centers for Disease Control and Prevention (CDC). 2020. Mortality Weekly Report (MMWR). https://www.cdc.gov/mmwr/volumes/69/wr/mm6947a6.htm. (Accessed November 28, 2022).
7. The U.S. Department of Veterans Affairs. 2022. National Veteran Suicide Prevention Annual Report. https://www.mentalhealth.va.gov/docs/data-sheets/2022/2022-National-Veteran-Suicide-Prevention-Annual-Report-FINAL-508.pdf
8. The U.S. Department of Veterans Affairs. 2020. National Center for Veterans Analysis and Statistics. https://www.va.gov/vetdata/veteran_population.asp (Accessed November 29, 2022).
9. Statista. 2022. https://www.statista.com/statistics/586712/iraq-afghanistan-veterans-with-current-medication-prescription/ (accessed November 30, 2022).
10. Military Times. https://www.militarytimes.com/pay-benefits/2018/12/04/one-in-four-troops-have-an-opioid-prescription-in-a-given-year/ (accessed November 30, 2022).
11. T. South, Military Times. https://www.militarytimes.com/news/your-military/2021/03/19/fda-regulated-study-shows-promise-for-using-marijuana-to-treat-veterans-with-ptsd/ (accessed Dec 1, 2022)
12. Disabled American Veterans (DAV). 2020. https://www.dav.org/veterans/resources/medical-cannabis/ (accessed Dec 1, 2022)

About the Authors

Dr. Marion McNabb, Julian Salim, DJ Ritter, and Vanessa Jones are with the Cannabis Center of Excellence (CCOE). Tom Rand is with Patriots Helping Vets. Dr. Steven White is a professor at UMass Dartmouth. Direct correspondence to: marion@cannacenterofexcellence.org.