Addictive Behaviors 42 (2015) 185188

Contents lists available at ScienceDirect

Addictive Behaviors

Short Communication

Characteristics of substance use disorder treatment patients using

medical cannabis for pain
Lisham Ashraoun a,b,, Kipling M. Bohnert c,d, Mary Jannausch c,d, Mark A. Ilgen c,d
a
Bowling Green State University, Department of Psychology, 207 Psychology Building, Bowling Green, OH 43403, USA
b
VA Ann Arbor Healthcare System, Mental Health Services, 2215 Fuller Rd., Ann Arbor, MI 48105, USA
c
VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), United State Department of Veterans Affairs, North Campus Research Complex, 2800 Plymouth Rd. Building 14,
Ann Arbor, MI 48109, USA
d
Department of Psychiatry, University of Michigan, North Campus Research Complex, 2800 Plymouth Rd. Building 10, Ann Arbor, MI 48109, USA

H I G H L I G H T S

Study was designed to assess correlates of medical cannabis use for pain.
15% of sample from substance use disorder treatment reported medical cannabis use.
Medical marijuana use for pain was associated with greater past-year substance use.
Research is needed to inform providers about medical cannabis use in drug treatment.

a r t i c l e i n f o a b s t r a c t

Available online 26 November 2014 Background: This study was designed to assess the prevalence and correlates of self-reported medical cannabis
use for pain in a substance use disorder (SUD) treatment program.
Keywords: Method: Participants (n = 433) aged 18 years and older were recruited from February 2012 to July 2014 at a large
Cannabis residential SUD treatment program. They completed a battery of questionnaires to assess demographics, usual
Substance use disorders
pain level in the past three months (using the 11-point Numeric Rating Scale for pain), depression (using the
Pain
Beck Depression Inventory), previous types of pain treatments, and lifetime and past-year use of substances
(using the Addiction Severity Index). Using both adjusted and unadjusted logistic regression models, we com-
pared those who reported medical cannabis use for pain with those who did not report it.
Results: Overall, 15% of the sample (n = 63) reported using medical cannabis for pain in the past year. After
adjusting for age, medical cannabis use for pain was signicantly associated with past-year use of alcohol,
cocaine, heroin, other opioids, and sedatives, but was not associated with usual pain level or depression. It was
also associated with past year treatment of pain using prescription pain relievers without prescriptions.
Conclusions: These results indicate that medical cannabis use for pain is relatively common and is associated with
more extensive substance use among SUD patients. Future work is needed to develop and evaluate strategies to
assess and treat individuals who report medical cannabis for pain in SUD treatment settings.
Published by Elsevier Ltd.

1. Introduction a paucity of research investigating characteristics of these individuals.

Existing surveys of medical cannabis use indicate that many of
individuals (4580%) seek medical cannabis for reasons related to
pain (Bonn-Miller, Boden, Bucossi, & Babson, 2014; Ilgen et al., 2013;
Nunberg, Kilmer, Pacula, & Burgdorf, 2011). Despite the considerable
proportion of individuals who seek medical cannabis for pain, there is
Corresponding author at: VISN 2 Center of Excellence in Suicide Prevention,
Canandaigua VA Medical Center, 400 Fort Hill Avenue, Canandaigua, NY 14424, USA.
Tel.: +1 585 393 7577; fax: +1 585 393 7985.
E-mail address: Lisham.ashraon@va.gov (L. Ashraoun).
The limited research has shown that recent and lifetime substance use
is more common in individuals seeking medical cannabis for any reason.
For example, Bonn-Miller et al. (2014) found that 16% of those who use
medical cannabis in the community met cannabis dependence criteria
and among individuals seeking medical cannabis licensure, Ilgen et al.
(2013) found that 68% of respondents reported nonmedical prescrip-
tion opioid use in the past 30 days.
Although these ndings are informative for those who use medical
cannabis generally, they do not provide information about how medical
cannabis use for pain is associated with other healthcare settings. Sub-
stance use disorder (SUD) treatment programs are likely to be affected

http://dx.doi.org/10.1016/j.addbeh.2014.11.024
0306-4603/Published by Elsevier Ltd.
186 L. Ashraoun et al. / Addictive Behaviors 42 (2015) 185188
by these broader changes in state cannabis-related policies because of
the high rates of substance use and substance-related problems
among those who use medical cannabis (Bonn-Miller et al., 2014;
Ilgen et al., 2013; Nunberg et al., 2011). In addition, research has
estimated that the rates of past-year pain in SUD settings range from
17 to 34% (Potter, Prather, & Weiss, 2008; Price, Ilgen, & Bohnert,
2011; Trafton, Oliva, Horst, Minkel, & Humphreys, 2004). This comor-
bidity is problematic given that pain is associated with poorer treatment
outcomes (Caldeiro et al., 2008; Larson et al., 2007; Potter et al., 2008;
Price et al., 2011; Trafton et al., 2004).
Despite the prevalence of pain in SUD treatment settings and the
likelihood that SUD patients may have obtained medical cannabis for
pain, little data on medical cannabis for pain are available among SUD
patients. The existing research that assessed medical cannabis use in
SUD treatment settings did not assess the extent to which patients were
using it to treat pain, were conducted with adolescents who had obtained
diverted medical cannabis (Salomonsen-Sautel, Sakai, Thurstone, Corley,
& Hopfer, 2012; Thurstone, Tomcho, Salomonsen-Sautel, & Prota,
2013) and was limited by small sample size (Swartz, 2010). Additional
research is needed to help characterize this subpopulation within SUD
treatment settings.
Therefore, the purpose of the present study was two-fold: (1) to
describe the overall prevalence of self-reported medical cannabis use
for pain and its correlates within a SUD treatment program for adults
and (2) to compare demographics, substance use, pain, history of pain
treatment, and depression between those who report medical cannabis
use for pain and those who do not. Based on the existing literature
regarding pain among SUD patients, it is hypothesized that medical can-
nabis use for pain will be associated with greater substance use and
higher pain and depression severity compared to those who do not re-
port medical cannabis use for pain.
2. Methods
2.1. Participants and procedures
Participants aged 18 years and older were recruited from February
2012 to July 2014 at a large residential abstinence-based SUD treatment
center. This center serves a large metropolitan area in the Midwestern
United States in a state where the medical cannabis use for pain,
among other conditions, is legal. To obtain approval for a medical canna-
bis card in this state, individuals submit an application that is signed by
a physician conrming that the individual has a qualifying debilitating
condition. Research staff not afliated with the center recruited partici-
pants at the site through presentations at treatment groups. Interested
participants were provided with additional information about the
study and provided written consent. All participants who could read
English and provide informed consent were encouraged to participate.
Participants (n = 433) completed the self-administered battery of
Table 1
Background characteristics comparing patients who have used medical cannabis for pain to patients who have not used medical cannabis for pain (N = 433).
Characteristic
Age (mean, SD)
Male
White
Currently married/partnered
Unemployed
Usual living arrangement
Jail
Other controlled environment (inpatient treatment, group home, etc.)
All other living arrangements
OR odds ratio and C.I. condence interval.
p 0.005; p-values were based on Wald chi-square test via logistic regression and Wilcoxon signed-rank tests.
questionnaires utilized for this study and were compensated for their
time. The study was approved by the Institutional Review Board. See
Table 1 for overall sample characteristics.
2.2. Measures
Past year use of cannabis for pain, in addition to other pain treatments,
was assessed using the following yes-or-no question, In the past year,
have you received any of the following treatments for your pain? with
the response option of medical marijuana and other treatments (see
Table 2). Lifetime and past-year substance use was assessed using items
from the drug use section of the Addiction Severity Index (ASI;
McLellan, Luborsky, Woody, & O'Brien, 1980), which is a commonly
used measure of substance use at the entry to SUD treatment. Participants
were asked to rate their average pain level over the past three months
using an 11-point Numeric Rating Scale (Farrar, Young, LaMoreaux,
Werth, & Poole, 2001) that ranged from 0 (no pain) to 10 (pain as
bad as you can image). The Beck Depression Inventory (Beck, Wright,
Newman, & Liese, 1993) was used to assess severity of depressive symp-
toms. Research supports the psychometric properties of this instrument
among those using substances (Buckley, Parker, & Heggie, 2001; Dum,
Pickren, Sobell, & Sobell, 2008).
2.3. Data analyses
Participants were grouped in either the medical cannabis group or
the no medical cannabis group based on whether or not they were
using medical cannabis for pain, respectively. Frequencies and percent-
ages of demographics, usual pain level, depression, pain treatments,
and substance use were calculated for the overall sample, and by group
and were compared via Wilcoxon signed-rank tests and chi-squares, re-
spectively, to analyze differences between those who reported using
cannabis for pain and those who did not use cannabis for pain in the
past year. Logistic regression modeling was used to examine associations
between substance use characteristics and medical cannabis use for pain.
Multivariate logistic regression models were conducted adjusting for
age. Unadjusted models and models adjusting for age were estimated
and odds ratio and 95% condence intervals are reported.
3. Results
Fifteen percent (n = 63) of the sample reported that they received
medical cannabis for pain management in the past year; whereas, 85%
(n = 370) reported no past year use of medical cannabis for pain
management. As shown in Table 1, the medical cannabis group
was signicantly younger (M = 28.7, SD = 9.2) than the no medical
cannabis group (M = 35.9 SD = 10.6). There were no other signicant
differences in demographic characteristics (see Table 1). In addition,
there were similar depression scores and usual pain levels in the past
Overall sample Past year medical cannabis use for pain
N = 433
Yes No
n = 63 (15%) n = 370 (85%)
34.8 (10.7) 28.7 (9.2) 35.9 (10.6)
295 (69%) 44 (70%) 251 (69%)
321 (74%) 49 (78%) 272 (73%)
64 (15%) 7 (11%) 57 (15%)
347 (80%) 47 (76%) 300 (81%)
170 (39%) 19 (31%) 151 (41%)
49 (11%) 10 (16%) 39 (11%)
212 (49%) 33 (53%) 179 (48%)
 L. Ashraoun et al. / Addictive Behaviors 42 (2015) 185188 187

three months between groups. There was no signicant association be-
tween medical cannabis use for pain and past year treatment of pain
using prescription pain relievers with a prescription; however, it was sig-
nicantly associated with past year treatment of pain using prescription
pain relievers without a prescription (opioids odds ratio [OR] = 3.35,
p b .005; other pain relievers OR = 2.73, p b .005; see Table 1).
After adjusting for age, lifetime substance use was not signicantly
associated with past year medical cannabis use for pain. Past year
alcohol (OR = 3.14; p b .005), cannabis (OR = 4.71, p b .005) cocaine
(OR = 2.17; p b .01), opioids other than heroin and methadone (OR =
3.03; p b .005), and sedative (OR = 2.63; p b .005) use were
signicantly associated with past year medical cannabis use for pain
(see Table 2).
4. Discussion
There are few studies that have investigated the prevalence of med-
ical cannabis use for pain in SUD treatment settings and those studies
have been limited to that of adolescents who did not have their own li-
cense (Salomonsen-Sautel et al., 2012; Thurstone et al., 2013). In the
current study, we found that 15% of patients at an abstinence-based
SUD treatment program reported medical cannabis use for pain within
the past year, although it is worth noting that the wording of the med-
ical cannabis item did not clarify whether the use was with or without a
state license.
We also found that those in the medical cannabis group were sig-
nicantly younger, with a mean age of 29, than those in the no med-
ical cannabis group. Research has demonstrated that a substantial
proportion of adolescent SUD patients use diverted medical cannabis
(Salomonsen-Sautel et al., 2012; Thurstone et al., 2013) and that
many rst-time applicants for medical cannabis are between the ages
of 18 and 30 (Ilgen et al., 2013). Therefore, future longitudinal research
is needed to assess the extent to which those seeking licensure for medi-
cal cannabis were originally using diverted medical cannabis. In addition,
future work should track the timing of medical cannabis use relative to
the onset of pain and the receipt of SUD treatment services.
We also found higher percentages of past year alcohol, cannabis, co-
caine, and other opioids among the medical cannabis group. These rates
were considerably higher than those found in studies of community
medical cannabis users and samples of individuals seeking initiation
or renewal of medical cannabis licensure (Bonn-Miller et al., 2014;
Ilgen et al., 2013). Overall, our ndings indicate that individuals using
medical cannabis for pain report having a more severe substance use
prole, including using prescription pain relievers without prescrip-
tions, even when compared with other patients in SUD treatment
settings. This is consistent with previous research demonstrating that
SUD patients who also have pain have more extensive substance use
compared to those with only one of these two conditions (Caldeiro
et al., 2008; Larson et al., 2007; Potter et al., 2008; Price et al., 2011;
Trafton et al., 2004), although we did not nd group differences in
pain level or depression. It may be that medical cannabis patients orig-
inally had higher levels of pain and cannabis use decreased pain to levels
that were similar to non-medical cannabis using patients; however,
those using medical cannabis for pain had comparable proportions of
other types of pain treatment compared to those not using medical can-
nabis for pain. Alternatively, it is possible that patients with extensive
substance use are more motivated to seek-out different sources of
substances, such as medical cannabis, as well as other substances and
that the measure of medical cannabis use for pain in this study is a
proxy for greater overall use of all classes of substances.

Table 2
Pain level and treatment, depression, and patterns of lifetime and recent use among substances (N = 433).

Characteristic Overall sample Past year medical cannabis use for Odds ratios
N = 433 pain

Yes No OR (95% C.I.) OR (95% C.I.)

n = 63 (15%) n = 370 (85%) (Unadjusted) Age-adjusted

Usual pain level (mean, SD) 5.4 (2.9) 5.6 (2.6) 5.4 (2.9) 1.02 (0.93, 1.12) 1.05 (0.95, 1.16)
Depression scores (mean, SD) 20.7 (12.2) 20.1 (11.0) 20.6 (12.4) 1.01 (0.98, 1.03) 0.99 (0.97, 1.02)
Treatments/activities done in past year for pain
Physical therapy 82 (19%) 12 (19%) 70 (19%) 0.99 (0.50, 1.96) 1.15 (0.57, 2.33)
Psychological treatment 78 (18%) 12 (19%) 66 (18%) 1.06 (0.53, 2.10) 1.01 (0.50, 2.05)
Rx opioids with rx 174 (40%) 28 (44%) 146 (40%) 1.22 (0.71, 2.10) 1.29 (0.74, 2.26)
Rx opioids without rx 196 (45%) 47 (75%) 149 (40%) 4.34 (2.37, 7.93) 3.35 (1.80, 6.24)
Other Rx pain relievers with rx 186 (43%) 26 (41%) 160 (43%) 0.92 (0.53, 1.58) 0.95 (0.54, 1.65)
Other Rx pain relievers without rx 163 (38%) 39 (62%) 124 (33%) 3.22 (1.85, 5.60) 2.73 (1.55, 4.81)
OTC pain medications 317 (73%) 50 (79%) 267 (72%) 1.48 (0.77, 2.84) 1.59 (0.81, 3.11)
Lifetime substance usea
Alcohol 413 (96%) 61 (97%) 352 (96%) 1.21 (0.27, 5.47) 0.91 (0.19, 4.40)
Cannabis 363 (84%) 60 (95%) 303 (83%) 4.22 (1.28, 13.9) 2.50 (0.73, 8.50)
Cocaine 322 (75%) 50 (82%) 272 (74%) 1.59 (0.79, 3.17) 1.50 (0.74, 3.08)
Heroin 233 (55%) 44 (70%) 189 (52%) 2.12 (1.19, 3.77) 1.61 (0.89, 2.93)
Methadoneb 172 (41%) 31 (50%) 141 (40%) 1.52 (0.89, 2.62) 1.23 (0.70, 2.14)
Other opioids 336 (78%) 56 (89%) 280 (76%) 2.46 (1.08, 5.59) 1.50 (0.63, 3.56)
Sedatives 298 (70%) 52 (84%) 246 (67%) 2.51 (1.23, 5.12) 1.65 (0.79, 3.47)
Tobacco 391 (90%) 58 (92%) 333 (90%) 1.29 (0.49, 3.41) 0.99 (0.36, 2.75)
Recent substance usea
Alcohol 251 (61%) 53 (85%) 198 (56%) 4.58 (2.19, 9.57) 3.41 (1.60, 7.29)
Cannabis 197 (47%) 51 (82%) 146 (41%) 6.60 (3.33, 13.1) 4.71 (2.31, 9.62)
Cocaine 167 (40%) 34 (57%) 133 (38%) 2.17 (1.25, 3.78) 2.17 (1.22, 3.84)
Heroin 153 (37%) 33 (53%) 120 (34%) 2.24 (1.30, 3.86) 1.54 (0.87, 2.73)
Methadoneb 78 (19%) 17 (28%) 61 (18%) 1.85 (0.99, 3.45) 1.37 (0.72, 2.62)
Other opioids 215 (52%) 49 (79%) 166 (47%) 4.27 (2.24, 8.14) 3.03 (1.55, 5.93)
Sedatives 200 (48%) 44 (73%) 156 (44%) 3.56 (1.94, 6.55) 2.63 (1.40, 4.94)
Tobacco 338 (82%) 55 (89%) 283 (80%) 1.92 (0.84, 4.39) 1.51 (0.64, 3.55)

OR odds ratio; C.I. condence interval; and Rx prescription.

p 0.05, p b .01, and p 0.005; p-values were based on Wald chi-square test via logistic regression.
a
Alcohol and substance use were assessed via ASI.
b
n = 23 (lifetime) to 35 (recent) refused to answer questions about methadone use.
188 L. Ashraoun et al. / Addictive Behaviors 42 (2015) 185188
The ndings of the current study should be interpreted with caution.
This study was conducted at one site and the results may not generalize
to others uses of medical cannabis or to other clinics, especially those in
other states that have different cannabis regulations. In addition, this
study was based on self-report and evaluated substance use using yes-
or-no questions; little is known about the frequency and negative
consequences associated with substance use. Future studies should
also include a more rigorous evaluation of medical cannabis use for
pain because the current study used one question that asked if partici-
pants used medical cannabis in the past year. Additionally, future
research should include a more extensive assessment of pain diagnoses.
These limitations notwithstanding, the present ndings highlight
the fact that many patients who enter SUD treatment have utilized
medical cannabis for pain and that treatment programs may want to
develop strategies to assess and treat individuals who report medical
cannabis use for pain. For example, treatment providers should consider
conducting thorough assessments of pain, the non-medical use of can-
nabis, and the extent to which medical cannabis may be interfering
with current treatment. Overall, the present literature does not provide
clear answers to questions about how best to respond to reported med-
ical cannabis use for pain in SUD patients. The present ndings indicate
that, at the very least, SUD treatment providers in states with laws
supporting medical cannabis use for pain should be aware that these
patients are likely to be relatively common and should develop policies
to assess for the use of medical cannabis and discuss how this might
relate to future recovery.
Role of funding sources
This study utilized data collected as part of NIDA grant R01DA029587. NIDA had no
role in the study design, collection, analysis, or interpretation of the data, writing the
manuscript, or the decision to submit the paper for publication.
Contributors
Dr. Ashraoun wrote the manuscript and incorporated the feedback of the other
authors into the nal draft of the manuscript. Dr. Bohnert assisted the conceptualization
of the manuscript, conducted some analyses, and revised versions of the manuscript.
Ms. Jannausch conducted the analyses and made the tables. Dr. Ilgen assisted the concep-
tualization of the manuscript and revised versions of the manuscript. All authors approve
of the nal draft of the manuscript.
Conicts of interests
All authors declare that they have no conicts of interest.
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