Among over 900,000 veterans on opioids, cannabis use was associated with 11% higher suicide attempt rates, and tobacco with higher rates of attempts, suicide deaths, and overdose deaths.
VA clinicians, pain management specialists, veteran suicide prevention researchers
HR 1.67 for overdose death among tobacco-using veterans on opioids
What the researchers found
Cannabis use: HR 1.11 for suicide attempts. Tobacco: HR 1.18 for attempts, HR 1.19 for suicide deaths, HR 1.67 for overdose deaths. Associations persisted after adjusting for substance use disorders, mental health, and sociodemographics.
Why it matters
Veterans on opioids are already at elevated risk. Identifying cannabis and tobacco as additional risk markers could inform screening and monitoring protocols.
The numbers in context
923,291 veterans. 5.4% cannabis, 39.4% tobacco. Median follow-up 6.7-6.8 years. Cannabis: HR 1.11 suicide attempt. Tobacco: HR 1.18 attempt, HR 1.19 suicide death, HR 1.67 overdose death.
How the study worked
Longitudinal cohort of 923,291 veterans receiving opioid analgesics in VHA clinics (2014-2019) with follow-up through 2021. Cause-specific hazard models adjusted for established suicide/overdose risk factors.
What this study cannot tell us
Observational. Cannabis/tobacco assessed at baseline only. Cannabis associated with attempts, not deaths. Residual confounding possible.
How to read the evidence
Very large national cohort with long follow-up and extensive adjustment, but observational design limits causal claims.
When this study was published
2026 publication using 2014-2021 VA data
The bigger picture
Identifying modifiable or monitorable risk markers could strengthen safety protocols without restricting necessary pain management.
Questions still open
- Is cannabis use causal or a marker for other risk factors? Would addressing tobacco in opioid-prescribed veterans reduce overdose deaths?
Common questions
Does cannabis cause suicide?
Why was tobacco more strongly linked to overdose death?
Read the original research
Associations of Cannabis and Tobacco Use with Suicide Attempt, Suicide Death, and Overdose Death Among Veterans Prescribed Opioid Analgesics.
American journal of preventive medicine, 108309
Citation
Nguyen, Nhung; Leonard, Samuel; Byers, Amy L; Austin, Peter C; Krebs, Erin E; Sandbrink, Friedhelm; Bravata, Dawn M; Keyhani, Salomeh. (2026). Associations of Cannabis and Tobacco Use with Suicide Attempt, Suicide Death, and Overdose Death Among Veterans Prescribed Opioid Analgesics.. American journal of preventive medicine, 108309. https://doi.org/10.1016/j.amepre.2026.108309
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