Secondary Logo

Journal Logo

Unhealthy Cannabis Use among Recreational and Medical Cannabis Users with Type 1 Diabetes

Camsari, Ulas M. MD1; Akturk, Halis K. MD2; Taylor, Daniel D. DVM, MPH3; Kahramangil, Doga MS2; Shah, Viral N. MD2

doi: 10.1097/CXA.0000000000000061
BRIEF COMMUNICATION
Free

Background: Cannabis is widely used among patients with type 1 diabetes (T1D) in Colorado. Despite increasing use of cannabis among patients with T1D, the frequency and characteristics of unhealthy cannabis use are unknown. We investigated the differences in unhealthy cannabis use in recreational and medical cannabis users with T1D.

Methods: Adult cannabis users with T1D completed an in-person questionnaire regarding their cannabis use patterns. They further divided into 2 categories; recreational and medical users. Cannabis Use Disorder Identification Test-Revised (CUDIT-R) was used to identify unhealthy cannabis use (CUDIT-R ≥ 8). Characteristics of cannabis users and unhealthy cannabis use between recreational and medical cannabis users were compared using unpaired t test.

Results: Out of 117 patients, 85 patients reported recreational and 32 patients reported medical cannabis use. Based on CUDIT-R scores, 37.6% of adults with T1D had unhealthy cannabis use. Frequency of cannabis use ≥4 times a week was higher among medical users compared to recreational users (59.4% vs 28.2%, P < 0.01). There was no difference between the groups in duration of cannabis use. There was no difference in mean overall CUDIT-R score (7.14 vs 7.5, P = 0.76) between recreational and medical cannabis users. There were also no significant differences in mean CUDIT-R score between recreational and medical users within the nonhazardous use category (3.70 vs 4.4, P = 0.15) and unhealthy cannabis use category (12.84 vs 12.67, P = 0.92).

Conclusions: Our study showed no difference in unhealthy cannabis use among recreational and medical cannabis users with T1D. Unhealthy cannabis use should be considered among users with T1D regardless of the reason for its use.

Contexte: Le cannabis est largement utilisé chez les patients atteints de diabète de type 1 (DT1) au Colorado. Malgré l’augmentation de la consommation de cannabis chez les patients atteints de DT1, la fréquence et les caractéristiques d’une consommation de cannabis malsaine sont inconnues. Nous avons étudié les différences entre la consommation de cannabis malsaine chez les consommateurs de cannabis récréatifs et médicaux atteints de DT1.

Méthodes: Les consommateurs de cannabis adultes atteints de DT1 ont rempli un questionnaire personnel sur leurs habitudes de consommation de cannabis. Ils ont été ensuite divisés en deux catégories; utilisateurs récréatifs et médicaux. Le Test d’identification des troubles liés à l’utilisation du cannabis révisé (CUDIT-R) a été utilisé pour identifier une utilisation malsaine du cannabis (CUDIT-R ≥8). Les caractéristiques des consommateurs de cannabis, ainsi que ceux d’une consommation de cannabis malsaine, entre les consommateurs de cannabis récréatifs et médicaux ont été comparées en utilisant un test t non apparié.

Résultats: Sur 117 patients, 85 patients ont signalé des activités récréatives et 32 patients ont déclaré avoir utilisé du cannabis à des fins médicales. D’après les scores CUDIT-R, 37,6% des adultes atteints de DT1 avaient une consommation de cannabis malsaine. La fréquence de consommation de cannabis ≥ 4 fois par semaine était plus élevée chez les utilisateurs de médicaments que chez les utilisateurs récréatifs (59,4% contre 28,2%, p < 0,01). Il n’y avait pas de différence entre les groupes quant à la durée de consommation de cannabis. Il n’y avait pas de différence dans le score CUDIT-R global moyen (7,14 vs 7,5, p = 0,76) entre les utilisateurs de cannabis à des fins récréatives et médicales. Il n’existait pas non plus de différence significative entre le score CUDIT-R moyen entre les utilisateurs récréatifs et les utilisateurs à des fins médicales dans la catégorie d’usages non dangereux (3,70 contre 4,4, p = 0,15) et dans la catégorie d’abus de cannabis (12,84 contre 12,67, p = 0,92).

Conclusions: Notre étude n’a montré aucune différence dans la consommation de cannabis malsaine chez les consommateurs de cannabis récréatifs et médicaux atteints de DT1. Une consommation de cannabis malsaine doit être envisagée chez les utilisateurs atteints de DT1, quelle que soit la raison de sa consommation.

1Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN

2Barbara Davis Center for Diabetes, University of Colorado, Aurora, CO

3School of Public Health, University of Colorado, Aurora, CO.

Corresponding Author: Halis K. Akturk, MD, Assistant Professor of Medicine and Pediatrics, Barbara Davis Center for Diabetes, University of Colorado, 1775 Aurora Ct Room 1319, Aurora, CO 80045. Tel: +1 303 724 0467; fax: +1 303 724 6784; e-mail: halis.akturk@cuanschutz.edu

The authors report no conflicts of interest.

Received July 9, 2019

Accepted April 30, 2019

Cannabis is the most commonly used illicit substance in North America.1–3 Public perspective about cannabis has changed over years resulting in the legalization of cannabis for medical use followed by recreational use in many states in the United States and recently in all provinces of Canada.4,5

Medical cannabis use refers to the use of cannabis to treat a disease or alleviate symptoms of a chronic medical condition.6 Type 1 diabetes (T1D) is a chronic disease that requires life-long insulin treatment. Cannabis use among patients with T1D is higher than the general population.7 Nearly 18% to 30% adults with T1D are using cannabis either for medical or recreational purposes in the United States.7,8 Patients with T1D use medical cannabis for a variety of reasons including diabetic neuropathy to alleviate pain and diabetic gastropathy to alleviate gastrointestinal symptoms without any constructive evidence.6,7

Cannabis use is generally perceived as safe and on the rise9,10 which is particularly concerning in the setting of a chronic medical illness such as T1D.11 Little is known about the potential negative consequences of cannabis use in the setting of T1D. Having access to one of the largest T1D populations in the United States, we aimed to evaluate problematic cannabis use patterns among recreational and medical cannabis users with T1D.

Back to Top | Article Outline

METHODS

Adults (≥18 years of age) with T1D attending Barbara Davis Center for Diabetes, one of the largest T1D centers in the United States between June 2017 and January 2018 completed an in-person questionnaire regarding their cannabis use and diabetes management. The relationship between cannabis use and diabetes outcomes from this study were reported previously.8 Cannabis use purpose was self-reported. Cannabis users further self-divided into 2 groups: medical and recreational. Medical cannabis use was defined in the questionnaire as using cannabis with a prescription by a certified healthcare professional. Pregnant patients and patients with diabetes other than T1D were excluded. The Colorado Multiple Institutional Review Board approved the study and all subjects provided written informed consent.

The Cannabis Use Disorder Identification Test-Revised (CUDIT-R) was used to identify the hazardous use of cannabis (score: ≥8 and <12) and possible cannabis use disorder (score ≥12).12 Hazardous use and possible cannabis use disorder categories were together defined as unhealthy cannabis use in our study. CUDIT-R is a screening test for problematic cannabis use and it is a revised version of CUDIT which was a direct modification of the Alcohol Use Disorders Identification Test.12 CUDIT-R questionnaire consists of 8 questions and has a sensitivity of 91% and specificity of 90% for identifying problematic cannabis use.12

Chi-square and 2-sample t tests were used for comparison of categorical variables and normally distributed continuous variables, respectively, between recreational and medical cannabis users. The primary outcomes were to compare the overall mean CUDIT-R score in adults with T1D by cannabis use reason (medical vs recreational) and to assess differences in means within CUDIT-R score categories (nonhazardous use and unhealthy cannabis use) for each use reason after controlling for differences in baseline characteristics. An exploratory outcome was to compare responses to individual CUDIT-R questionnaire questions between recreational and medical groups. Participants with combined cannabis use (medical and recreational) were excluded from the analysis due to inability to define the primary reason for use (n = 16). Difference in overall CUDIT-R score means by use reason and differences in means within the nonhazardous cannabis use and unhealthy cannabis use categories by use reason were assessed using an unpaired t test. P values were considered significant below a 0.05 level.

Back to Top | Article Outline

RESULTS

Out of 631 eligible patients, 449 patients (71.3%) responded to the survey. Age, gender, and diabetes characteristics were similar between responders and nonresponders. Out of 449 responders, 133 patients (30%) reported cannabis use in the last 12 months. Among cannabis users, 85 patients reported recreational use (63.9%), 32 patients (24.1%) medical use, and 16 patients (12%) both. Baseline characteristics of adults with T1D by cannabis use reasons are provided in Table 1. Missing baseline characteristic data were found to be missing completely at random and minimal (<3). Compared to recreational users, medical users were older, had higher income and more likely to be female. Smoking was the most common form of cannabis use in this cohort. Medical users tended to use cannabis more than 4 times a week more frequently than recreational users (59.4% vs 28.2%, P < 0.01). There was no difference between the groups in duration of cannabis use.

Table 1

Table 1

Based on CUDIT-R scores, 37.6% of adults with T1D had unhealthy cannabis use (CUDIT-R ≥ 8), which includes hazardous cannabis use (20.5%) and possible cannabis use disorder (17.1%). There was no difference in mean overall CUDIT-R score (7.14 vs 7.5, P = 0.76) between recreational and medical cannabis users. After controlling for baseline characteristics, there were also no significant differences in mean CUDIT-R score between recreational and medical users within the nonhazardous use category (3.70 vs 4.4, P = 0.15) and unhealthy cannabis use category (12.84 vs 12.67, P = 0.92) (Table 2).

TABLE 2

TABLE 2

Compared to recreational cannabis users, medical cannabis users had a higher mean score for the question assesses the frequency of cannabis use in CUDIT-R questionnaire (2.9 vs 2.2 average scores, P < 0.01). However, this did not change the overall CUDIT-R scores between medical and recreational users.

Back to Top | Article Outline

DISCUSSION

Cannabis use for medical purposes has been steadily increasing in the state of Colorado in conjunction with legislative changes,7,8 this is of particular concern in the setting of chronic disease, T1D is no exception. Our diabetes center has access to a very large T1D population which has been increasingly exposed to cannabis in different forms recently. We aimed to explore and compare use patterns within a population that unhealthy use definition could apply.

Among unhealthy users with T1D, we found no difference between recreational and medical use categories. We found a higher frequency of use in medical use category, this however could be due to the way medical cannabis prescription was written. Interestingly, despite a higher frequency of cannabis use for medical purposes, CUDIT-R scores were not different among medical and recreational use categories.

There are several limitations of this study. First, CUDIT-R is a screening test to identify the population at risk and we used as a screening method for capturing problematic use of cannabis.13–15 There are 11 diagnostic criteria for substance use disorders in DSM-V which CUDIT-R essentially attempts to screen.16 Ideally, a positive CUDIT-R questionnaire result should follow an addiction evaluation by a clinician for a comprehensive diagnostic assessment to determine whether a valid addictive use pattern exists. Second, our criterion for medical use was limited to reported prescriptions which limited our ability to capture medicinal use without prescription. Third, our T1D population did not have any comparison group which would have allowed us to determine if frequency of use or CUDIT-R severity were higher among T1D.

With the increasing trend of using cannabis in North America, physicians should be aware of the risk of unhealthy cannabis use among patients with T1D. Small sample size, single center, and self-reported cannabis use are limitations of the study. Future research directions should include further understanding the cannabis use patterns in prescribed and nonprescribed users, study designs relying on clinical evaluations for increasing diagnostic validity, randomized control studies focusing on cannabis use in T1D and other chronic diseases.

Back to Top | Article Outline

REFERENCES

1. Hasin DS, Sarvet AL, Cerda M, et al US adult illicit cannabis use, cannabis use disorder, and medical marijuana laws: 1991–1992 to 2012–2013. JAMA Psychiatry 2017;74:579–588.
2. Monte AA, Zane RD, Heard KJ. The implications of marijuana legalization in Colorado. JAMA 2015;313:241–242.
3. Wadsworth E, Hammond D. International differences in patterns of cannabis use among youth: prevalence, perceptions of harm, and driving under the influence in Canada, England & United States. Addict Behav 2018;90:171–175.
4. Imtiaz S, Kurdyak P, Samokhvalov AV, et al Trends in treatment of problematic cannabis use in Ontario's specialized addiction treatment system from 2010/11 to 2015/16: a repeated cross-sectional study of a health administrative database. CMAJ Open 2018;6:E495–E501.
5. Kim HS, Hall KE, Genco EK, et al Marijuana tourism and emergency department visits in Colorado. N Engl J Med 2016;374:797–798.
6. Whiting PF, Wolff RF, Deshpande S, et al Cannabinoids for medical use: a systematic review and meta-analysis. JAMA 2015;313:2456–2473.
7. Petry NM, Foster NC, Cengiz E, et al Substance use in adults with type 1 diabetes in the T1D exchange. Diabetes Educ 2018;44:510–518.
8. Akturk HK, Taylor DD, Camsari UM, et al Association between cannabis use and risk for diabetic ketoacidosis in adults with type 1 diabetes. JAMA Intern Med 2019;179:115–118.
9. Lloyd SL, Striley CW. Marijuana use among adults 50 years or older in the 21st century. Gerontol Geriatr Med 2018;4:2333721418781668.
10. Camchong J, Lim KO, Kumra S. Adverse effects of cannabis on adolescent brain development: a longitudinal study. Cereb Cortex 2017;27:1922–1930.
11. Humphreys K, Saitz R. Should physicians recommend replacing opioids with cannabis? JAMA 2019;PMID: 30707218. [Epub ahead of print].
12. Adamson SJ, Kay-Lambkin FJ, Baker AL, et al An improved brief measure of cannabis misuse: the Cannabis Use Disorders Identification Test-Revised (CUDIT-R). Drug Alcohol Depend 2010;110:137–143.
13. Dharmawardene V, Menkes DB. Substance use disorders in New Zealand adults with severe mental illness: descriptive study of an acute inpatient population. Australas Psychiatry 2015;23:236–240.
14. Chabrol H, Beck C, Laconi S. Contribution of health motive to cannabis use among high-school students. Addict Behav 2017;64:54–56.
15. Dharmawardene V, Menkes DB. Violence and self-harm in severe mental illness: inpatient study of associations with ethnicity, cannabis and alcohol. Australas Psychiatry 2017;25:28–31.
16. American Psychiatric AssociationDiagnostic and Statistical Manual of Mental Disorders. 5th ed.Washington, DC: American Psychiatric Association; 2013.
Keywords:

addiction; cannabis; CUDIT-R; marijuana; type 1 diabetes; dépendance; cannabis; marijuana; CUDIT-R; diabète de type 1

© 2019 by Lippincott Williams & Wilkins, Inc.