After a traumatic event it is common to experience psychological distress. Most individuals recover from such an event without persistent psychological effects. However, some people develop posttraumatic stress disorder (PTSD), which can lead to long-lasting aftereffects such as nightmares, hyper-arousal state, difficult memories, trouble sleeping or concentrating, anxiety, depression, flashbacks, and emotional detachment.[1,2]
PTSD is even more prevalent among military personnel because of their participation in warzones. The U.S. Department of Veterans Affairs (VA) estimates that PTSD afflicts 31% of Vietnam veterans, 10% of Gulf War (Desert Storm) veterans, 11% of Afghanistan veterans, and 20% of Iraq veterans.
The consequences of PTSD on the individual, their families, and society can be overwhelming. PTSD places individuals at a higher risk for suicide, substance abuse, depression, and violence.4 The VA estimates that up to 22 former members of the Armed Forces commit suicide per day. Furthermore, PTSD has been shown to lead to other health issues such as coronary heart disease, gastrointestinal symptoms, and higher overall mortality.[6,7]
CURRENT PTSD TREATMENTS OFFER LIMITED SUCCESS
Treatment for PTSD is limited and the success rate remains low. The mainstay of treatment options includes Selective Serotonin Reuptake Inhibitors (SSRIs) such as Paxil and Zoloft. However, these medications have side effects such as weight gain, decreased libido, drowsiness, and nausea. Second-line pharmaceuticals include Effexor, Prazosin, Monoamine oxidase inhibitors, and tricyclic antidepressants, which tend to have more side effects.
A recent review of psychotherapies for military-related PTSD showed suboptimal outcomes. The most frequently utilized trauma-focused psychotherapies for military-related PTSD are Cognitive Processing Therapy (CPT) and Prolonged Exposure. Trauma-focused therapies are considered first line therapies, yet they are only marginally superior to non-trauma-focused therapies. A form of cognitive behavioral therapy (TF-CBT), trauma-focused therapy is a psychosocial treatment model that helps patients confront their beliefs, emotions, and memories associated with the traumatic event. Non-trauma-focused therapies, such as Present-Centered Therapy (PCT), concentrate on teaching coping skills; for example, stress management, problem-solving, and relaxation. PCT utilizes problem-solving techniques to focus on the patient’s existing skills to cope with stressors associated with PTSD.
THE TIDE TURNS TOWARD MEDICINAL CANNABIS
Another potential PTSD treatment among military personnel is medical cannabis — although it has proven difficult to use due to government regulations. The VA Hospital system and their physicians must follow federal law, which still classifies cannabis as a Schedule I drug, with no accepted medical use and a high potential for abuse.
The tide, however, is starting to change, albeit slowly. The Veterans Equal Access Act was introduced in November 2014. It directs the Secretary of VA to authorize VA healthcare providers to: (1) provide veterans with recommendations and opinions regarding participation in their state’s cannabis programs, and (2) complete forms reflecting such recommendations and opinions. It is currently in the Subcommittee on Health.
How did medical cannabis enter the picture? Since there is a dearth of effective treatment options for PTSD, patients who experimented with medical cannabis started to report improvement in their symptoms. Several studies showed efficacy in reduction of symptoms associated with PTSD and medical cannabis including a study on Nabilone (a man-made form of cannabis), an endo-cannabinoid receptor agonist, which decreased nightmares in PTSD patients.
The endo-cannabinoid system (ECS) is distributed throughout the brain and the body. In the brain, the ECS regulates synaptic release of excitatory and inhibitory neurotransmitters. The ECS may play a role in homeostasis by preventing severe cortical excitation and inhibition, and it may be impaired in some mental diseases.
HOW DOES MEDICAL CANNABIS HELP WITH PTSD SYMPTOMS?
Some specific effects of medical cannabis, such as sedation, relaxation, reduction of anxiety and sleep-induction, may explain its use as an attempt to cope with some PTSD symptoms. Sleep disorders, such as nightmares and insomnia, are reported in over 70% of patients diagnosed with PTSD.11 There are several hypotheses on how some of these effects are achieved. There is a very high concentration of endo-cannabinoid receptors (CB1) in the areas of the brain that are involved in the processing of memory, emotional reactions, decision-making and the fear system (hippocampus, amygdala, limbic system). Endocannabinoids may provide an amnestic effect and have a role in the extinction (“forgetting”) of unpleasant memories.[13,14]
In response to stress, the body releases the hormone cortisol to help mitigate the biological changes associated with stress. However, repeated exposure to stress and prolonged secretion of cortisol can lead to harmful effects on the body. Research has shown that the ECS regulates structures that are involved in cortisol secretion (Hypothalamic-Pituitary-Adrenal Axis). In turn, medical cannabis may reduce the emotional impact of traumatic memories through a complex set of mechanisms that might facilitate sleep and reduce anxiety in people with PTSD.
Unfortunately, not all the effects from medicinal cannabis are positive. Some people report side effects such as anxiety[16,17], paranoia, and sleep disturbances, which can all exacerbate the PTSD symptoms individuals are using medical cannabis to treat in the first place. Further research is necessary to illuminate which cannabinoids provide good treatment options with the least side effects; for example, a high cannabidiol and low tetrahydrocannabinol (CBD:THC) ratio. Some of the undesirable side effects have been attributed to THC.
There has been significant progress in the diagnosis and treatment of PTSD. However, better long-term treatment options are necessary. As with most psychological issues, combination therapy is the most effective. Pharmacotherapy, by itself, will not resolve the issue.
Dr. Pouya Mohajer is a Diplomate of the American Board of Anesthesiology with a subspecialty in pain medicine, and founder of the Nevada Cannabis Medical Association.
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