PTSD and Cannabis
Updated: Nov 14, 2020
Throughout the last 25 years of treating patients with Post-Traumatic Stress Disorder (PTSD) I have noticed what they have noticed. Medicine has its limitations. PTSD can lead to such desperation that when the foundational support of therapy does not work and life becomes unbearable, medications are used to control symptoms. But do they fix PTSD? Let us dive into the new “budding” treatments and therapies to find out why so many patients are turning toward cannabis with or without their physician’s help.
Post-traumatic stress disorder is diagnosed with a list of criteria that need to be met. The DSM 5 is the psychological Bible that helps psychiatrists diagnose certain conditions. Excerpted criteria from the DSM 5 states that the initial stressor can be a direct injury or exposure or a witnessed trauma. Sometimes it can be an indirect exposure as in the case of first responders and medics that may see trauma in relationship to their professional duties. The trauma can be suffered by a relative or close friend and the patient assumes that trauma for him or herself. The classic symptoms that define this disorder include nightmares, flashbacks, emotional distress after exposure, physical reactivity after exposure to traumatic triggers, and upsetting memories. To be officially diagnosed with PTSD the patient must either have trauma-related feelings or trauma-related external reminders. There are some very classic negative mood or cognitive changes that also may be present to help define the diagnosis. These include negative affect (most commonly depression), decreased interest in activities, isolation, exaggerated blame, inability to recall features of the trauma, or overly negative thoughts about oneself or the world. Patient symptoms need to have lasted at least one month or more and there are some alterations in arousal and reactivity which are quite specific to this condition. These are worsened after a trauma in the following ways: irritability or aggression, destructive behavior, hyper vigilance, a heightened startle reaction, difficulty concentrating, and difficulty sleeping. Do not be alarmed if you have some of these traits. A disorder is diagnosed once the distress causes significant functional impairment socially or occupationally.
Now that we have gone through the technical assessment of PTSD, we need to dive into the reasons why many people are turning to cannabis and why this sacred plant may offer the key to treating this disorder most effectively. There are several pharmaceutical drugs derived from cannabis. What does "Big Pharma" already know? Certain medications have gotten approval for treatment of pain and spasticity as in the case of Sativex which is using THC and CBD components. Marinol has been on the market a long time to treat cancer, AIDS, neuropathic pain, and multiple sclerosis specifically targeting the nausea and wasting. Nabilone is a synthetic cannabinoid like THC. There are several medications in the laboratories that have not been approved for use (yet) in the United States including Dexanabinol, CT-3, Cannabinor. There are even a few in trials that are designed to block our endocannabinoid receptors to help with obesity. This cannot be a stretch, then, to understand why patients may want to use cannabis to help their PTSD. How do we propose that it helps with this condition?
Two recent studies point to the way that cannabinoids may help treat PTSD. One shows how cannabis can reduce activity in the amygdala. The amygdala is one of two almond shaped nuclei deep within our temporal lobes. They are in our limbic system which processes memory, decision-making and emotional responses such as fear and anxiety. Wayne State studied the amygdala responses in three groups of participants - healthy controls who had not been exposed to trauma, trauma exposed adults without PTSD and trauma exposed adults with PTSD. Using a randomized, double-blind controlled procedure, the 71 participants were either given a low dose of THC or a placebo. Then they were exposed to threatening stimuli and their amygdala responses were recorded. The bottom line is that those exposed to THC had lowered threat-related amygdala reactivity. Another study suggests that the plant’s cannabinoids could play a role in extinguishing traumatic memories. This small study is now being researched on mice and seems to capitalize on anandamide. This is our own chemical that we make which is like THC. It is considering our “bliss molecule” and helps us lessen or “forget” traumatic stimuli. At NYU Langone Medical Center they have shown that patients with PTSD have a lower amount of this neurotransmitter anandamide; therefore, cannabis can be used to activate the CB1 and CB2 receptors in our bodies to maintain higher levels of anandamide. The CB1 cannabinoid receptor is purported to help shut the traumatic memories off. Think of anandamide as being our own natural antidepressant.
Cannabis effects do not just stop at the limbic system and anandamide changes. Cannabis also can relieve symptoms such as poor sleep and nightmares. Proof was in the use of nabilone (the one medication mentioned above) to stimulate cannabinoid receptors. In doing so sleep was restored and nightmares significantly reduced. Keep in mind that there are several portions of the cannabis plants that get called into action including cannabinoids, terpenes, and flavonoids. Medication only uses one compound and researches that one effect to get approval on the market. Using all portions of the plant naturally reaps the benefit of several compounds. However, this makes it hard to regulate as a medication, and maybe we never want to regulate it!
Military veterans have an exceedingly high rate of PTSD for obvious reasons. Canada has some early information that cannabis use in their veterans seems to help reduce depression and suicidal ideation. They loosely define the medical cannabis use as “low-level” and does not include any participants that have “cannabis use disorder.” Overuse of cannabis may affect dopamine or make certain anxieties worse, so some caution is advised. In the US, the “Veteran’s Equal Access Act of 2019” now allows private physicians (not VA physicians) to complete state-legal medical marijuana paperwork. It has also been my experience that the questions on those forms specifically address whether PTSD is service-related or not. This offers the statistics needed to assess the need and benefit of cannabis in our veterans. There is also a study finishing up the results and currently tabulating the effects of smoking cannabis for those VA PTSD participants in Colorado.
I have witnessed anecdotal benefits from my patients. The patients who’ve benefited are immeasurable, and they verify that cannabis can be life-saving and can rid the awful side effects of anti-depressants, anti-psychotics, and mood stabilizers (that don’t alleviate the PTSD symptoms anyway). So, let us summarize the strains of plants that have particular benefit for the PTSD patient. “Blue Dream” originated from California and has high THC sativa as its dominant underpinning. Since sativa can be stimulating it is usually used in the daytime but can give a gentle and calm euphoria. High indica THC promotes sedation. “Pineapple Express” has the added benefit for some inflammatory and migraine help in addition to the PTSD and mood disorders. Since it has a high sativa-dominant THC percentage it can promote worsening generalized anxiety. However, if lifting the mood, adding creativity and heightened productivity is the goal, this one may be the best fit. “OG Kush” also has a high THC potency with some growers bragging of 25% sativa and 75% indica with incredibly low CBD aids in the euphoria but also total body calming. The added indica percentage help with nightmares and insomnia. “Cannatonic” is a 50/50 sativa/indica strain, however, the THC component is low and CBD portion is high (up to 20%). This makes it quite calming with little psychoactive effect. “Northern Lights” is an indica strain and immensely popular because of its fast-acting sedative effect when you need sleep or quick de-escalation from panic. “ACDC” also has remarkably high CBD component with low THC. Given the high CBD strain recreational users do not find a big high with it, but for pain, alcoholism, seizures, and PTSD this may be a mild option when mild treatment is needed. Let us finally give a shout out to our Colorado “Golden Goat” medical strain which has a high psychoactive THC sativa component. It provides a balanced mind/body effect.
Both the condition of PTSD and the cannabis/marijuana treatment of same are far less stigmatized as we advance our understanding forward. Studies are few and hard to fund given the federal stance on marijuana. Patients should consider a cannabis-friendly physician who can help navigate the co-morbid medical conditions and medications in addition to the medical marijuana contribution to the treatment. I would also recommend a medical marijuana shop since recreational strains may complicate the treatment or lead to side effects which may discourage the novice from continuation. A knowledgeable owner or grower is worth the investment to help your physician co-manage your condition. To be eligible for medical consideration you must get your medical card (“red card” in Colorado) through a participating physician.