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One More Time Just to Kill the Pain: On Medical Marijuana and Post Stress Disorder

David Cohen has a PhD in clinical criminology and worked in forensic psychiatry for 28 years. He also suffers from chronic back pain.

PTSD Sufferers Believe that Cannabis Relieves Symptoms

Since the mid 1990s, studies have repeatedly shown that people suffering from PTSD use marijuana to alleviate their symptoms, particularly symptoms related to hyper-arousal and sleep disturbances. A recent Australian study reported that in an online sample of people who used “illicitly obtained” marijuana for self-described medical problems, 59.2% used it for anxiety and 69.2% for sleep disorders- both of which are frequent symptoms of PTSD. Almost 23% mentioned PTSD specifically as the reason for their use. The users also reported a variety of undesirable side effects, and spending large sums of money to obtain the illegal substance.

Medical marijuana has since been legalized in Australia, and it is indicated for use in several countries around the world (including Israel, where I live) and in many of the United States. However, as Dr. Marcel Bonn-Miller pointed out in his 2015 MAPS article, this doesn't necessarily mean that cannabis is “good” for treating PTSD. I have to agree, in principle: Over the years, I have seen many people who suffer from Schizophrenia and use heroin to alleviate the terrors of hallucinations. That doesn't mean heroin is a cure for Schizophrenia (it isn't) or that it is 'good' for the patient (again: it isn't). Similarly, Cannabis use in PTSD patients can reflect an addiction, a maladaptive coping mechanism, or it may lead to avoidance of other treatments.

PTSD Sufferers Believe that Cannabis Relieves Symptoms- But "Science" Hasn't Figured it Out Yet

The fact that PTSD sufferers have an affinity for cannabis shows that PTSD sufferers perceive cannabis as helpful for alleviating symptoms. It doesn't mean that there isn't something more effective. As the authors of the recent Australian study point out, there is no “hard evidence” on the efficacy of medical marijuana in treating PTSD. Bonn-Miller got funding to complete a serious, definitive study, which is still ongoing.

On the other hand, as Robert T. Muller points out in a December 2017 Psychology Today article, there is ample anecdotal evidence that while cannabis doesn't “cure” PTSD (I have to admit: I have been diagnosed with PTSD, and both as a patient and a professional I'm not sure anything can cure it), there is ample anecdotal evidence that it can effectively relieve symptoms. Also, my argument about Schizophrenia and heroin doesn't really hold water: PTSD isn't a degenerative psychotic disorder like schizophrenia, and cannabis isn't nearly as dangerous a substance as heroin. For one thing, while an overdose of cannabis can be extremely unpleasant and very scary, it won't cause you to stop breathing or your heart to stop beating, like an overdose of heroin will. Cannabis also has a much higher tolerance level and is less addicting than heroin. If you stop using cannabis, the withdrawal symptoms won't make PTSD symptoms worse, whereas withdrawal from opioids can exacerbate symptoms of schizophrenia.

Since Muller published his study, a paper published in "The Mental Health Clinician" revealed that antidepressants commonly prescribed for PTSD are extremely ineffective, "and may require 9 patients to be treated for 1 to have a response. After reviewing the literature, the authors conclude: "Although some positive data exists for the use of marijuana in PTSD, current evidence is limited to anecdotal experiences, case reports, and observational studies, which leads to a lack of quality evidence to currently support the use of marijuana to treat PTSD". Since then several other reports published in 2018, in prestigious journals such as "Frontiers in Neuroscience" and "Neuropsychopharmacology" have reached similar conclusions.

Would You Jump from a Plane Without A Parachute?

Have you ever heard of parachutes? In two very serious pieces published in the BMJ, one from 2003 and the other from 2006, the authors pointed out that there are no “double blind clinical trials” of parachutes. There is even anecdotal evidence that people may die while jumping from high places while using a parachute and there are recordings of a few who even survived a jump without one (Google "Luke Aikins", if you don’t remember). But no reasonably sane person would jump out of a plane or off a high-enough cliff without one (Aikins doesn't count. He is an accomplished sky-diver, and he executed an excruciatingly planned jumped into a specially designed net). Were society to wait for a double blind trial of parachutes before mandating (or even allowing) their use, dozens of people would probably die. And, as the authors of the 2006 paper pointed out- many people do die because modern science equates "evidence based" with "double blind study", ignores common sense and anecdotal evidence and refuses to approve treatments that are commonly known to be effective.

As the authors of a followup, 2018, BMJ study on parachutes point out:

Although decades of anecdotal experience have suggested that parachute use during jumps from aircraft can save lives, these observations are vulnerable to selection bias and confounding. Indeed, in seminal work published in the BMJ in 2003, a systematic search by Smith and Pell for randomized clinical trials evaluating the efficacy of parachutes during gravitational challenge yielded no published studies

Apply this logic to medical cannabis. People who use it to alleviate PTSD related symptoms report that it alleviates their symptoms. Why waste money on expensive, never ending clinical research? Remember: It took the FDA years to round up 76 Vets with PTSD who met inclusion criteria in a phase-3 study, and the study is still ongoing.

At worst, legally regulated cannabis will do no harm, whereas at worst, illegal, unregulated cannabis can kill. For one thing, there's no way to know what's in it or what quality it is, or if the particular strain one has purchased is really the one he needs (There are hundreds of strains of cannabis, and as any qualified expert will tell you, some make anxiety worse).

The Israel Experience

Israel legalized medical cannabis for use with PTSD patients in 2014. The criteria for obtaining a license are relatively straightforward: "medium" level PTSD or worse, with at least 30% disability and significant psychological stress for at least three years and at least two failed conventional drug treatments and two unsuccessful attempts at psychotherapy. Exclusion criteria are a history of psychosis or of substance abuse.

It is not especially easy to get a medical marijuana license in Israel, but it is a relatively straightforward process, if you meet the inclusion criteria. According to a report published on an Israeli website, in 2018 there were about 30,000 medical cannabis users in Israel (recreational cannabis is largely decriminalized in Israel, but still illegal), and about 2,800 used it for relief of symptoms caused by PTSD. Medical cannabis costs about 120 dollars a month here: The government regulates the price, which is fixed regardless of the amount of cannabis a patient is allotted (for example, I pay the same amount for 30 grams a month- more than enough to help me deal with both by back pain and my PTSD- as someone with more severe symptoms who gets 50 or 60 grams a month). The cannabis is of reliable quality and locally grown, and every dispensary has help-desk to assist patients in matching the proper strain to their needs. Many Israeli activists complain that the process takes too long and forces patients to endure years of suffering and ineffective treatments. Due to the aforementioned affinity PTSD sufferers have for cannabis, many PTSD sufferers are exposed to the hazards of using illegally obtained marijuana, at high cost and health risk.

Conclusion

Cannabis is the PTSD sufferer's parachute. In Israel, like in many US states where medical marijuana is indicated for use to alleviate PTSD, the ministry of health has no problem jumping from a plane with a parachute, despite lack of "scientific evidence" and based on the observation that in 99.9% of the cases, parachutes seem to prevent one from smashing into jelly on landing. However, the "jump" is made only in dire circumstances and when other more conventional methods of getting safely out have failed or are ruled probably ineffective. It can only be hoped that continuing research worldwide will validate what everyone already knows about medical marijuana and PTSD, and that medical marijuana will become more easily and more readily available to those who need it.

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