The association between moral injury and cannabis use disorder among Israeli combat veterans: current state of knowledge and future directions

Background: Cannabis use is highly common among military combat veterans, who are also inclined toward developing Cannabis Use Disorder (CUD). In recent years, growing attention is drawn to the effect of moral injury (MI), a shame and guilt-based trauma-related syndrome which may occur following combat-related acts that violate one’s deep moral beliefs. However, little is known concerning its association with to CUD, as well as possible factors which may interact with this possible association.

Methods: A mixed-methods study was conducted among Israeli combat veterans who reported using cannabis regularly (≥3 days weekly) during the past six months (n=325). Participants completed a set of validated self-report questionnaires. Among those who screened positive for CUD, 20 participants also completed in-depth interviews. No funding was received.

Results: MI 'self-committed transgressions' subscale was significantly associated with CUD symptoms. The MI-betrayal subscale was significantly associated with CUD symptoms, yet time since release from military duty moderated this association: among participants with low (M=2.08 years) or average (M=6.09) time since release, ‘MI – Betrayal’ was signifncanly associated with CUD symptoms (b=.35, p<.001, b=.27, p<.001, 95%, respectively). However, when the years since release were high (M=10.11), no significant association was found between betrayal and CUD (b=.07, p=.49).

Qualitative analyses revealed a meta-theme labeled 'from enchantment to disillusion' dominant among newly released veterans and a meaning-making process which enabled older veterans a more adaptive processing of MI-related events.

Discussion: MI may be an important predictor of CUD among veterans and should be assessed and addressed when treating veterans suffering from CUD.