The 2019 Veterans Health and Medical Cannabis Study

Dr. Marion McNabb and colleagues report on the findings from the anonymous 2019 Veterans Health and Medical Cannabis Study, which was a national and Massachusetts-focused research study led by McNabb, Stephen Mandile, leading Iraqi War Veteran and medical cannabis advocate, and Dr. Stephen White, Professor at UMass Dartmouth. The study’s main objective was to collect anonymous, self-reported data from US military veterans regarding their current health conditions, conventional medical treatments, medical cannabis use, and its effectiveness with self-reported health conditions and symptoms, and issues related to access and stigma.

As of 2020, there are more than 18 million veterans in the United States, with over nine million veterans who access healthcare each year provided by the Department of Veterans Affairs (VA)(1). Every year, more than 200,000 veterans transition out of service (2).

US military service members and veterans often face particular and comorbid health issues more than their civilian counterparts because they are at risk for different injuries during their service. These could be combat or stress related, and many injuries are life-threatening or can cause long-term disability. Additionally, service members are also at higher risk for health problems related to exposure to environmental hazards such as contaminated water, chemicals, infections, and burn pits. 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 (3).

Research points to the early transition period for veterans as a critical time to support them with the readjustment period and its associated challenges (2). Vogt and colleagues conducted a five-year study with a nationally representative sample of more than 9500 US veterans during their first year after military service. The study assessed veterans’ well-being over time related to health, work, and social relationships over three intervals. The study, published in March 2020, found that health concerns were the top issues, with 53% of veterans reporting chronic physical pain and 33% reporting chronic mental health conditions. The top conditions reported included: chronic pain, sleep problems, anxiety, and depression (4).

Veterans reported overall that they were less satisfied with their health than either their work or social relationships after returning home (4). Zone deployed veterans reported more health concerns, and women reported more mental health concerns compared to their nondeployed and male peers (5).

The VA reports that veterans suffer from chronic pain, with around 60% of veterans returning from combat, and 50% of elder veterans reporting suffering from chronic pain.Nationally, 30% of Americans suffer from chronic pain (6).

The resulting and compounding health conditions that veterans face post-deployment comes with the need for healthcare, numerous prescription medications, and mental health interventions.

Nguyen and colleagues published a study in 2017 that looked into the prevalence of medication dispensing across VA and non-VA care providers among a group of veterans. The study included a cohort of more than 52,000 veterans and found that on average they were prescribed 40 medications per year, and 17.4% of them had medication use from non-VA sources, including antibiotics, antineoplastics, and anticoagulants. The non-VA and VA medication sources were not in the same health records, causing fragmented care and documentation of medications (7).

Another survey conducted in 2020 of 1700 US Iraq and Afghanistan veterans found that 46% were prescribed anti-depressants, 35% anti-anxiety medications, 36% sleeping pills, and 32% opioids (8). An additional study led by the Defense Department found that nearly one in four active-duty members had at least one prescription for an opioid at some point in 2017. The study also noted that about one in four veterans had at least one opioid prescription, yet only one tenth of a percent (0.001%) of veterans were receiving care for a diagnosed opioid use disorder (9).

Based on our research and findings in the studies described above, we set out to conduct our own study in 2019 to discover how medical cannabis was helping veterans in Massachusetts and nationally. The study’s main objective was to collect anonymous, self-reported data from US military veterans regarding their current health conditions, conventional medical treatments, medical cannabis use, and its effectiveness with self-reported health conditions and symptoms, and issues related to access and stigma. Here we report on some of our findings from that study.

Before we delve into our own data, we’d like to provide some additional context for the various ailments facing veterans. Specifically, high addiction rates and PTSD are more common in veterans than the general public. Let’s take a closer look at those two conditions, the available treatments, and the ways in which cannabis has been effective.

Addiction Rates

Military deployment is associated with smoking, unhealthy drinking, illicit drug use, and risky behaviors. There is a zero-tolerance policy for veterans that mandates random drug testing and often discourages veterans from seeking help. Service members can be dishonorably discharged and face criminal prosecution for a positive drug test.

According to the US National Institutes of Drug Abuse (NIDA) more than 1 in 10 veterans have been diagnosed with a substance use disorder (SUD), which is slightly higher than the general population. Veterans are also impacted by issues related to substance abuse, including pain, suicide risk, trauma, and homelessness (10).

In terms of substances, cannabis is the vast majority of illicit drug use among veterans. Historically, the VA has not recognized medical cannabis, and thus has recorded cannabis positive drug tests as cannabis use disorder (CUD). From 2002–2009, CUDs increased more than 50% among veterans treated at the VA (10).

Opioid and other prescription drug misuse is a major issue with the veteran community, post deployment. From 2001–2009 military physicians wrote nearly 3.8 million prescriptions of pain medications, with the percent of veterans in the VA who received an opioid prescription increasing from 17–24%, quadrupling the amount from 2001 (10). The opioid overdose rates of veterans increased from 14% in 2010 to 21% in 2016 (10).

More recently, self-reported use of prescriptions for pain have decreased. From 2011-2015 the percent of reported use of pain medications decreased by nearly half (10).

Among veterans who present for the first time for care with the VA, nearly 11% meet the criteria for an SUD. It is reported that about 20% of high-risk behavior deaths among veterans were attributed to alcohol or drug overdose (10).

Additionally, veterans who have an SUD also may have comorbid conditions such as PTSD, depression, and anxiety. In fact, veterans with SUDs are 3–4 times more likely to be diagnosed with PTSD or depression (10). Among recent Afghanistan and Iraq veterans, NIDA reports that 63% of those who were diagnosed with having an SUD met the criteria for PTSD (10).

Veterans also face disproportionate rates of suicide compared to their civilian counterparts. In fact, in 2017, 16.8 veterans committed suicide per day and the suicide rate for veterans was 1.5 times the rate for non-veteran adults (1). In 2017, a VA-funded study of nearly 124,000 veterans found that those who received the highest doses of opioids were twice as likely to die of suicide than those receiving the lowest doses (10).

Post-Traumatic Stress Disorder

According to the American Psychiatric Association (APA), PTSD is a “psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event such as a natural disaster, a serious accident, a terrorist act, war/combat, or rape or who have been threatened with death, sexual violence or serious injury.” PTSD can affect any person, any nationality, culture, or at any age. People with PTSD face disturbing thoughts and feelings related to their traumatic experience that can last a long time after the event. Events are relived through flashbacks, nightmares, and they may also feel sadness, fear, anger, or detached from other people. People with PTSD often avoid situations that remind them of the traumatic event and may have strong negative reactions to something as ordinary as an accidental touch or loud noise (11).

Several PTSD scales are commonly used to diagnose PTSD severity, including the PTSD checklist called the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) Post-traumatic Stress Disorder Checklist (PCL-5), which is a self-reported questionnaire required by the VA for veterans being treated for PSTD (12).

PTSD prevalence among veterans varies greatly by wars and eras. According to a study conducted by Reisman and colleagues of Iraq and Afghanistan veterans, 13.5% of deployed and nondeployed veterans screened positive for PTSD whereas other studies showed rates as high as 20% and 30% (12).

According to the national Veterans’ Affairs, the number of veterans who suffer from PTSD varies by service era:

• Between 11–20% for those who served in Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF)
• 12% of those who served in the Gulf War (Desert Storm)
• 30% for those who served in the Vietnam War have had PTSD in their lifetime

Another cause of PTSD in the military can be military sexual trauma (MST). According to the VA, 23% of women reported sexual assault when in the military, and 55% of women reported experiencing sexual harassment when in the military. Also, 38% of men report having experienced sexual harassment while in the military (13).

PTSD often has associated comorbidities, with depression being the most common. Data reported by Reisman and colleagues in a review of what’s working for treatment of PTSD in veterans showed that major depressive disorder is nearly three to five times more likely to emerge in those with PTSD than not. Physical pain is also associated with PTSD. Veterans returning from Iraq and Afghanistan report chronic pain to be one of the most common symptoms, with 15–35% of patients with chronic pain reporting to also have PTSD (12).

Additionally, anxiety and substance abuse or dependence is also common among those who suffer from PTSD. The VA reports that more than 2 out of 10 veterans with PTSD also have an SUD, and almost 1 out of every 3 veterans seeking treatment for an SUD also has PTSD (13).

How Is PTSD Currently Treated?

Psychological interventions are the first line of treatment for PTSD among veterans, cognitive processing therapy (CPT) and prolonged exposure (PE) therapy are the most common approaches (12). Eye-movement desensitization and reprocessing (EMDR) is also recommended as an effective first-line treatment. Pharmacological interventions are common as a second- or first-line treatment approach. Antidepressant medications called selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are the preferred class of medications, and studies show only 20–30% of patients achieve complete remission with using an anti-depressant (12).

There are currently four antidepressants that are recommended by the VA for those who suffer with PTSD: Sertraline (Zoloft), Paroxetine (Paxil), Fluoxetine (Prozac), and Venlafaxine (Effexor) (14). SSRIs have side effects including insomnia, drowsiness, nausea, dizziness, nervousness, agitation, dry mouth, headache, blurred vision, and sexual problems (15). The VA has a treatment decision aid application to help veterans find the right therapy or medication for managing their PTSD symptoms (16).

The economic consequences of having PTSD are high for veterans. The first-year treatment for Iraq and Afghanistan veterans treated through the VA is estimated to be $8300 per person. The healthcare costs, overall, are 3.5 times higher for veterans with PTSD than those without the disorder (12).

Medical Cannabis and PTSD

The use of medical cannabis to treat symptoms of PTSD has emerged as a possible alternative therapy, however, the evidence related to treatment efficacy is conflicting. A recent comprehensive literature review published in 2017 by Klimkiewicz and Jasinska looked at more than 10,000 peer-reviewed publications and reported that there is still a need for conclusive research related to the impact of cannabis for those who suffer with PTSD. The review noted that cannabis use does not appear to increase the likelihood of developing depression, anxiety, and PTSD (17).

As of 2018, 16 states had approved the use of medical cannabis for those who suffer with PTSD (18). However, there is currently a lack of population level data and controlled studies of cannabis use and PTSD in the US. Additionally, studies are reporting conflicting data as to the clinical benefits of medical cannabis for those with PTSD, and specifically veterans who have PTSD.

In 2015, Betthauser and colleagues conducted a literature review of the use of cannabis for PTSD among veterans. The search found 11 research studies pertaining to cannabis use by veterans who suffered from PTSD. Some studies reported a direct correlation between more severe PTSD symptomatology and increased motivation to use cannabis for coping purposes. Data from four small studies suggested that cannabinoid use was associated with global improvements in PTSD symptoms or amelioration of specific PTSD symptoms such as insomnia and nightmares (19).

One study by Jetly in 2015 found a significant positive effect of cannabis in reducing PTSD-associated nightmares (20). In addition, cannabis use as motivation to improve sleep in PTSD patients seems to be strongly correlated (21).

In 2018, Shishko and colleagues published a systematic literature review to understand the use of cannabis among those suffering with PTSD. The review found five studies that evaluated the use of cannabis for PTSD. Three studies were found to have a benefit, and two studies were found to have a statistically significant difference in worse PTSD outcomes (18).

However, more recently, in 2019 researchers Lake and colleagues in Canada conducted an analysis of health survey data from more than 24,000 Canadians and concluded that people who have PTSD but do not medicate with cannabis are far more likely to suffer from severe depression and have suicidal thoughts more so than those who reported cannabis use over the past year (22). The authors noted that their study was the first nationally representative survey to show promising benefits of treating PTSD with cannabis and reducing severe depression and suicidal states. They reported that with such limited options for treating PTSD, many have taken to medicating with cannabis (22).

Other researchers in a US Department of Defense funded study found that cannabis use may increase suicidality in military personnel with elevated PTSD symptoms. In a study of 545 veterans in a one-year study, they found that cannabis use and PTSD symptoms increased suicidal behavior over an 11-month period (23).

O’Neil and colleagues in 2017 published a systematic literature review to understand the benefits and the harms of cannabis for PTSD. They found two systematic reviews and three observational studies that were deemed to have a high risk of bias, but noted there are several ongoing research studies to look at the efficacy (24).

LaFrance and colleagues analyzed data from 400 Strainprint (cannabis journaling mobile application) users and found the sustained reduction of symptoms of PTSD among cannabis consumers who self-reported PTSD diagnosis (25).

Cannabis research in the US is very difficult to conduct because cannabis is still federally illegal. This limits researchers and academic institutions that receive federal grants or funding from participating. To conduct a clinical trial with cannabis in the US, researchers must use cannabis from only one approved source—the University of Mississippi. Often the cannabis produced from that source is not representative of the cannabis available widely on the market (17).

To date, there has only been one clinical trial completed in 2019 to evaluate the use of cannabis as a treatment for PTSD symptoms. The leading researcher, Dr. Sue Sisley of the Scottsdale Research Institute and the Multidisciplinary Association for Psychedelic Studies (MAPS), worked for 10 years from the start of the research design, through regulatory approval, and conducting the study. The results are being analyzed currently for publication (26).

Veterans Support for Medical Cannabis and Research

Despite the conflicting research findings, veterans are continuing to advocate for the use of medical cannabis as an alternative to the often-deadly cocktails of prescription medications and opioids they are currently prescribed.

In 2017, an American Legion study found that 92% of veterans supported research into medical cannabis and 82% reported wanting to have cannabis as a federally legal treatment. Eighty-three percent (83%) of veterans reported that the federal government should legalize cannabis (27). The American Legion has called for the VA to invest in research for cannabis to be an alternative treatment for PTSD (27).

Since 2018, the Disabled American Veterans (DAV) have included public pushes for medical cannabis use and research for veterans (28). Specifically, the DAV called for research into cannabis as an alternative pain relief option for those who suffer from PTSD, pain, and traumatic brain injuries (TBI) (28).

Iraq and Afghanistan Veterans of America’s (IAVAs) most recent national survey showed that one in five members use medical cannabis. However, fewer than one third of veterans mentioned cannabis use to their VA doctor because of fear of loss of jobs or reprisal from the VA (29).

Methods

The anonymous 2019 Veterans Health and Medical Cannabis Study was a national and Massachusetts-focused research study led by Dr. Marion McNabb, CEO of Cannabis Community Care and Research Network (C3RN), Stephen Mandile, leading Iraqi War Veteran and medical cannabis advocate, and Dr. Stephen White, Professor at the University of Massachusetts (UMass) Dartmouth. The study’s main objective was to collect anonymous, self-reported data from US veterans regarding their current health conditions, conventional medical treatments, medical cannabis use and its effectiveness with self-reported health conditions and symptoms, and issues related to access and stigma.

The research study utilized a 100+ question anonymous survey online and recruited US veterans to take the survey using a convenience sampling approach. The online survey was developed by Cannabis Community Care and Research Network, UMass Dartmouth, and Mandile. The survey questions were developed using standard scales found in the literature, with input from Dr. Staci Gruber from McLean Hospital and Harvard Medical School.

The study instrument was approved by the UMass Dartmouth Charlton College of Business Institutional Review Board. The survey was powered by SurveyMonkey and participants were recruited through study partners. Study partners were provided their own unique links to share the survey through their respective social and email listservs. Press releases of data were sent to the local media for TV and print publication, promoting preliminary findings to drive policy change.

In addition to the research study, the team launched the Cannabis Advancement Series (CAS) together with Joint Venture and Co., leading six community education events in Massachusetts regarding veterans’ access and highlighting the need for alternatives. Data from the study was reported at each of the events to promote community awareness and change for veterans in Massachusetts. Please refer to www.cannabisadvancementseries.org for the events and speakers who advocated in 2019 for veterans access. Nine primary study partners were recruited to support sharing and funding the study, however the study had more than 39 supporters.

Results and Discussion

Data collection lasted from March 3 through December 31, 2019, and a total of 565 US veterans completed the survey, of which 201 (36%) were from Massachusetts. Veterans reported from 48 states, including Puerto Rico and the District of Columbia.

Among all veterans who responded, 30% were rated as 100% disabled by the VA (the average disability rating is 56%), and 83% of total respondents were male. More than 50% of those who responded were above the age of 50, and 79% identified as white.

Of those who responded, 31% served in the War in Iraq (Operation Iraqi Freedom), 24% did not serve in a war, 21% served in the Vietnam War, 18% served in the Persian Gulf War, 14% selected “Other war,” 13% served in the War in Afghanistan, and 8% served in Operation New Dawn. Please see Table I for additional data.

Table I

In terms of the branch of service, 50% of respondents were in the Army, 21% were in the Navy, 17% were in the Air Force, and 16% were in the Marines. Veterans reported being exposed to several toxins during deployment, with 33% exposed to burn pits, 25% asbestos, and 12% Agent Orange.

According to the VA Combat Exposure Scale, 52% of veterans reported moderate to heavy combat exposure, and 30% reported being homeless currently or in the past.

In terms of health conditions veterans were facing in our sample, 38% reported chronic pain as the top health condition, followed by 25% PTSD, and 9% anxiety.

Nationally, veterans reported using on average 4.1 medications a day to manage their conditions and spent $98.40 a month out of pocket for prescription or over the counter medications. Only 16% of veterans in our sample reported not having any kind of health insurance. Nationally, 30% of respondents reported having over the counter or prescription medications at their home that they do not use and need to get rid of. In addition, 56% reported getting their prescriptions mailed to them from the VA, and only 5% reported being diagnosed for an opioid use disorder in the past, with 1% currently diagnosed.

Among the symptoms veterans reported having, 68% reported depression, 68% sleep problems, 64% pain, 57% anxiety, and 37% attention deficit disorder.

In terms of cannabis use, 92% reported consuming medical cannabis, and 72% of veterans have consumed cannabis for 13 months to more than 10 years.

Among those who reported medical cannabis use, the top conditions they reported it being the most helpful for included: 37% chronic pain, 25% PTSD, 11% anxiety, and 7% depression.

Veterans were asked to identify all health conditions (in addition to the top condition) that they found cannabis helpful for. Overall, 70% reported it useful for pain, 64% anxiety, 57% depression, 53% PTSD, and 37% insomnia. Please see Tables II–VI for additional data.

Table II

Table III

Table IV

Table V, part 1

Table V, part 2

Table VI

In terms of side effects of medical cannabis use, 68% reported dry mouth, 35% increase energy, and 35% changes in appetite.

Nationally, 78% of veterans reported actively trying to reduce the use of unwanted over the counter or prescription medications with medical cannabis. SeeTable VII for additional data.

Table VII

PTSD and Cannabis Use

Among those who reported PTSD as their top condition, 75% scored a PTSD positive score when completing the DSM-5 (PCL-5) checklist that the VA uses to clinically diagnose PTSD. A total score of 50 is considered to be PTSD positive in the military, and veterans in our sample had an average score of 59. In our national sample, 25% of veterans reported PTSD as their top condition (n = 144) for which cannabis was most helpful.

In our study, 144 veterans nationally identified PTSD as their top condition (n = 144) for which medical cannabis is helpful. Nationally, veterans reported spending an average dollars per week (N = 565) of $85.77 or $343.08/month on medical cannabis. This average was slightly lower than those who reported PTSD, who report spending $91.99/week or $367.96/month. Veterans with PTSD (N = 144) report spending $85 a month on prescriptions compared to our national veterans’ sample (N = 565), who report spending $98 a month on prescriptions.

Among veterans with PTSD in our national sample, 35% report reducing antidepressants with the use of medical cannabis, compared to 26% of the national sample reporting reducing antidepressant use with cannabis. Additionally, among those with PTSD, 11% of respondents report reducing opioid use with cannabis, compared to 17% of the overall national sample reducing opioid use with medical cannabis.

For veterans with PTSD, 68% (n = 91) report using alcohol much less with the use of cannabis, 19% less, and 12% report about the same. In terms of quality of life, veterans with PTSD report 66% greater daily quality of life much more, and 31% more. In addition, 78% report using opioids much less now, and 43% reported using prior non-opioid medications much less now, 29% less now, and 28% about the same. Among those with PTSD, 50% reported smoking tobacco much less now, 29% about the same amount of use, and 17% less now.

Among veterans with PTSD, 94% reported cannabis helps them experience psychological symptoms (anxiety, stress, sadness) much less or less now. Additionally, 96% of veterans with PTSD report they experience a greater or much greater quality of life due to their cannabis use.

In terms of barriers to accessing medical cannabis among veterans in our national sample who have PTSD (n = 144), the largest barriers include (note that veterans could select all that apply): 57% money to purchase products; 46% access the right products; 36% stigma; 33% owning a firearm; 33% money to get a medical card; 28% workplace testing; 27% place to consume cannabis; 16% lack of knowledge; and 5% previous bad experience.

In terms of VA provider and policy related to medical cannabis use, as of VHA directive 1315 issued on December 8, 2017, it is VA policy that VHA providers and pharmacists should discuss cannabis use with veterans as it is relevant to their clinical care. They are however prohibited from being state-licensed cannabis providers, but still encouraged to discuss with their patients how cannabis can be used for their clinical care, including possible interactions with the medications they are taking and this information must be recorded.

In our sample, we found that the majority of veterans have reported medical cannabis use to their VHA provider, but 63% do not know if they support it.

With the VA mandating that the providers should discuss cannabis use with veterans, we found in our sample that this dialogue is not happening. Generally, veterans report finding out medical cannabis information from other informal, non-clinical sources, yet the majority of veterans in our sample (78%) report using cannabis currently or in the past as an alternative to other medications.

Discussion

The 2019 Veterans’ Health and Medical Cannabis Study collected anonymous data nationally from veterans with a focus on Massachusetts. The community education arm, the Cannabis Advancement Series, was a collaboration with UMass Dartmouth, C3RN, Stephen Mandile, and Joint Venture & Co. The team conducted the research study and held local educational events to share data and findings to inform local policy change for veterans’ access to alternatives, as part of the study design.

Through this study, investigators were able to document current health conditions faced by veterans and understand their medical cannabis use and its impact on health conditions and symptoms reported by veterans. The data in our study align with national reports of health conditions faced by veterans.

The top conditions reported in our study found that medical cannabis is useful for chronic pain, PTSD, and anxiety. These findings are similar to other studies in the literature reporting relief with these main conditions.

An overwhelming majority of veterans are using cannabis as a harm reduction method to replace other lethal and more toxic substances. Approximately 78% of the veterans in our sample report actively or in the past having used medical cannabis to reduce prescription and over the counter (OTC) medications. Among those with PTSD, higher rates of reducing the use of anti-depressants with the help of medical cannabis was reported.

Given that anti-depressants are the most common form of treating PTSD, these findings are pointing to veterans preferring medical cannabis as a treatment. This is similar to the findings by Lake and colleagues who recently completed a nationally representative study in Canada, which reported that veterans are preferring medical cannabis to the existing PTSD treatments and prescription medications.

Despite its potential to improve the quality of life for many veterans, the top two barriers reported that veterans face for access are related to cost—thus limiting access. Nationally, veterans report spending $98 a month on prescription medications, and an average of $343 a month for medical cannabis. Medical cannabis is not covered by insurance and can be very costly for a veteran who is on disability.

Medical cannabis use among veterans in our sample is reported effective for improving quality of life, improving clinical, physical, and psychological symptoms, and reducing the use of unwanted medications. Despite its effectiveness, veterans are currently in a difficult position to access a medical cannabis card, receive effective guidance from their VA provider, and access the funds needed to get the cannabis in the amounts they need for medical relief. With veterans being more likely to suffer from chronic health problems, suicide, and PTSD, there is a need to continue to not only conduct further research on the benefits, but also start to develop dosing guides and other clinical tools to integrate medical cannabis as an alternative treatment (15).

Conclusion

US Military veterans in our research study reported the use of medical cannabis for a variety of health conditions, including chronic pain, PTSD, and anxiety. Veterans reported that the use of medical cannabis greatly improves their physical and mental health conditions, and an overwhelming majority of veterans are using cannabis as an alternative to prescription or over the counter medications. Barriers to use include cost and healthcare provider awareness. Further inquiry using more rigorous research study designs will help to further identify appropriate use of medical cannabis for a variety of health conditions veterans face.

Acknowledgements

The authors want to give a special thank you to all the veterans for your service and for sharing your anonymous results for this study to drive change in access to alternatives. This study would not have been possible without you. Thank you also for the support, sharing, and collaboration of the following primary study funding and in-kind support partners: Thorn Law Group, Giovanni DeCunto, Laer Realty, AmeriCann, Bask, Cannabis Creative Group, The Disabled American Veterans (DAV) Massachusetts Chapter, MCR Labs, Revolutionary Clinics, The Botanist, The Healing Rose, and Weedmaps. Additional thanks to Central Ave, Insa, and Good Chemistry for their support as study coupon partners.

Thank you to Dr. Staci Gruber from Harvard/McLean and to the DAV and the IAVA for their study collaboration. Thank you to the media partners who helped recruit participants: Sensi Magazine, NECANN, Different Leaf Magazine, Weedmaps, local MA press, and clinical partner Dr. Dustin Sulak, Healer.com.

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About the Authors

Marion McNabb, DrPH, MPH is the President of Cannabis Center of Excellence, INC (CCOE) a 501c3 nonprofit organization that conducts citizen-science focused population studies and programs in the areas of community engagement, medical cannabis, adult-use cannabis, and social justice in the cannabis industry. The CCOE serves as a virtual resource and network of cannabis industry professionals, academics, policy makers, healthcare providers, consumers, and patients who aim to break the stigma and advance social justice in the cannabis industry. The CCOE, INC is currently running a COVID-19 cannabis patient and consumer study: www.cannacenterofexcellence.org. Dr. McNabb is the former CEO and cofounder of the Cannabis Community Care and Research Network (C3RN), a Massachusetts-based cannabis research company from 2018–2020 that aimed to improve the evidence-base related to medical cannabis therapies. C3RN, with UMass Dartmouth, led a two-year open cannabis consumer and patient research study to assess the impact on health, social, and economic outcomes. C3RN also led the Veterans Health and Medical Cannabis Research Study with UMass Dartmouth, and partners. C3RN was an approved qualified training vendor for the Massachusetts Cannabis Control Commission’s social equity training program. Dr. McNabb also holds more than 15 years of global public health experience working in the areas of digital health, HIV/AIDS, maternal and child health, and family planning, working primarily in Africa and Haiti. She received her DrPH from Boston University School of Public Health and her MPH from the Johns Hopkins University School of Public Health.

Stephen Mandile is an Iraq War Veteran and cannabis advocate.

DJ Ritter is a Data Analyst at the Cannabis Center of Excellence, Inc.

Ann Brum is the president and CEO of Joint Venture & Co.

Rachel Bacon, Randal MacCaffrie, Dawson Stout, Alexander Nicholas Rewegan, and Erica Tangney are with the Cannabis Center of Excellence, Inc.

Dr. Stephen White is with UMass Dartmouth and Charlton College of Business.