The Use of Medical Cannabis to Treat Post Traumatic Stress Disorder

I. Introduction

Currently, there are approximately 500 suicides a month in patients with Post
Traumatic Stress Disorder (PTSD) and over three hundred thousand backlogged
disability claims involving PTSD and depression. n1. Those suffering from PTSD also
have a reduced quality of life, an increased number of hospitalizations, high frequency of
depressions and alcohol drug abuse, and suffer in social, family, and work life. n2. For
patients who are treated, many have poor responses to psychotherapy and
pharmacological treatment and often turn to alcohol and drugs. n3.

Recent studies demonstrate the potential benefits of the use of cannabis for
PTSD. These studies confirm that extinction of aversive memories and the adaptation to
stress responses are in part, controlled by endocannabinoids. n4. There are two
cannabinoid receptors in the brain, CB1 and CB2. These receptors are activated by:
endocannabinoids, which are synthesized internally in the body, cannabinoids derived
from the cannabis plant (such as THC), and synthetic cannabinoids that are synthesized in
a laboratory. This natural system works much like our natural GABA system. Just as we
produce our own endocannabinoids, we produce our own internal GABA, and we use
synthetic benzodiazapines that bind to the receptors. Likewise, we have cannabinoid
receptors, and we should be using cannabis to modulate them. Cannabinoids can act as a
therapeutic target for the treatment of diseases associated with the inappropriate retention
of aversive memories, such as PTSD. n5 Furthermore, because of the effects of the
cannabis on the stress response, it is likely that potential patients treated with
cannabinoids may also benefit from the stress-reversing effects of the drug. n6

While the state of Arizona has acknowledged and approved the use of cannabis
for many physical illnesses such as multiple sclerosis and chronic pain, it has failed to
acknowledge the use of cannabis for psychological disorders such as PTSD, in which the
medical benefits of cannabis are scientifically proven. This reflects unfounded
discrimination on mental illness and psychological disorders. As Nancy Pelosi stated in a
recent address on health care, “Illness of the brain must be treated just like illness
anywhere else in the body.” n7. Recently, the federal government has expressly
acknowledged this in its passage of the Mental Health Parity and Equalization Act of
2008, mandating that health care providers provide equal treatment for mental
disorders/substance abuse disorders as it does for any other physical illness. n8 The
stereotype that psychological illnesses are any less debilitating or credible than physical
illnesses is unacceptable and has no basis in science or reality. In both cases people are
sick and need care; in both cases there are treatments that can relieve them of pain. When
people receive the necessary treatment, people have the potential to get better and be
productive and independent citizens. n9.

Hundreds of recent studies indicate that cannabis is an effective treatment for

PTSD. Considering the high suicide rate associated with PTSD (50-100 suicides a month
for veterans alone) n10, and that accepted psychotherapeutic and pharmacological
treatments are often ineffective, n11, it is imperative that PTSD patients have access to
another option that is effective, natural, safe, and can be regulated by a doctor. These are
people, often veterans, whose chronic psychological trauma, depression, insomnia, and
accompanying symptoms cannot be relived by conventional therapy or
psychotherapeutics and is worsened by alcohol. n12. In fact, since the U.S. sent more
than 1.6 million men and women into combat in Iraq and Afghanistan in 2001, 18.3% of
those returning have PTSD or major depression. n13. These patients have fought for our
country and are now plagued with horrible memories. Their health and quality of life
should be of top priority, and studies show and patients have testified that cannabis is an
effective, alternative treatment. Cannabis can help relieve these patients of psychological
trauma, it can stop horrible nightmares and stress related sleep disorders, and it can
provide them with a better quality of life. n14

II. The Effectiveness of Cannabis as a treatment for PTSD.

a) The endocannabinoid system reverses enhancing effects of stress and helps

with retention of aversive memories.

Over the past few years, remarkable advances have been made in our
understanding of the endocannabinoid system and its molecular and physiological
functions. n15. The potential therapeutic value of cannabinoid modulation is highlighted
by the dense expression of the cannabinoid CB1 receptor in regions known to be
significant for anxiety and emotional learning, particularly the basolateral amygdala
(BLA). n16.

The endocannabinoid system has specific involvement in the habituation

component of fear extinction and mediates habituation to repeated stress, suggesting that
augmentation of endocannabinoid signaling is a good target for the treatment of affective
disorders. n18, n19. The endocannabinoid system has a direct effect on the natural brain’s
function of dealing with information and can in fact aid the brain in discarding unneeded
information. n20.

The functions of the endocannabinoid system are especially relevant to the

treatment of conditions associated with retention of aversive memories and stress related
disorders, such as PTSD. A recent study examining the cannabinoid receptor activation
in the BLA found that it reverses the enhancing effects of environmental stress on
inhibitory avoidance (IA) conditioning and its impairing effects on extinction. n21. The
study tested rats, known for their love of dark places, who were given electric shocks
when entering the darkened region of their cage. Shortly thereafter, the rats became afraid
of the dark area and began to remain in the brighter part of the cage. The researchers then
stopped giving the electric shock treatment and the rats returned to the dark area. The
length of time between the shocks stopping and the rats returning was measured. In the
next phase of the study, a new group of rats were used. These rats were shocked as they
entered the dark area of the cage and were placed on an elevated grid. (Most animals,
including rats, avoid walking over elevated grids as they find the distressing). It took
longer for this group of rats to trust the dark region again. The researchers then tested a
third group of rats, who were treated in the same way as the second group, except in this
group a synthetic THC-like compound was injected into a the BLA, the region of their
brains associated with fear. This medical-marijuana receiving group of rats returned just
as quickly to the dark spot in the cage as the rats in group one. n22.

The beneficial effects of cannabinoids in the BA are extremely significant.

Specifically, the study found that: 1) cannabinoid receptor activation in the BA blocks
the effects of stress on the conditioning and extinction of inhibitory avoidance (IA); 2);
cannabinoid receptor stimulation in the BLA reduces stress-induced elevations in
corticosteroid levels (this is significant because most people with PTSD show a high
secretion of cortisol), n23; and (3) the CB1 receptor has an extremely important role in the
BLA in the extinction of avoidance behavior because the receptor antagonist impairs IA
extinction. n24. These findings show that cannabinoid receptor activation can act to
reverse the effects of stress on memory. These results support a wide therapeutic
application for the cannabis cannabinoids in the treatment of conditions in which patients
suffer from aversive memories and stress. PTSD patients should be entitled to a treatment
that can have such a profound beneficial effect on relieving traumatic memories.

b) Cannabinoids are effective in cessation of nightmares and a reduction in

nightmare intensity

The disruption of sleep is often one of the most debilitating parts of PTSD and
patients are often unable to find relief through pharmaceutical treatment. n25.
Particularly, nightmares and sleep disorders are frequent symptoms of PTSD, with some
patients experiencing even more severe problems such as violent or injurious behaviors
during sleep, sleep paralysis, and hypnagogic and hypnopompic hallucinations. n26, n27.

Recent studies have shown that cannabis is effective in cessation of nightmares

and reduction of nightmare intensity. In a study evaluating the effects of an
endocannabinoid receptor agonist on treatment-resistant nightmares in patients diagnosed
with PTSD, patients who had continued nightmares despite treatment with conventional
anti-depressants and hypnotics were reviewed after treatment with nabilone, an
endocannabinoid receptor agonist. n28. A large majority (72%) of patients experienced
either cessation of nightmares or a significant reduction in nightmare intensity. n29.
Furthermore, patients noted improvement in sleep time, the quality of sleep, and the
reduction of daytime flashbacks and night sweats. n30.

These findings are extremely significant because they not only illustrate the many
benefits of cannabis on PTSD symptoms, but also that cannabis can be an effective
option for patients who are unable to find relief with the currently accepted treatments.
Dr. Tod Mikuriya, psychiatrist, author, and former marijuana research for the National
Institute of Health, emphasized the importance of treating sleep deficits in those with
PTSD when he explained, "PTSD often involves irritability and inability to concentrate,
which is aggravated by sleep deficit. Cannabis use enhances the quality of sleep through
modulation of emotional reactivity. It eases the triggered flashbacks and accompanying
emotional reactions, including nightmares. The importance of restoring circadian rhythm
of sleep cannot be overestimated in the management of PTSD.” n31.

c) Cannabinoids promote neurogenesis and produce anxiolytic and

antidepressant like effects.

The hippocampus is able to generate new neurons (neurogenesis) throughout the

lifespan of mammals. n32. Studies teach us that newborn hippocampal neurons are
functionally integrated into the existing circuitry and are positively correlated with
learning and memory processes and the developmental mechanisms of stress and mood
disorders. n33. Recent studies have shown that chronic treatment with synthetic
cannabinoids produces antidepressant and anxiolyic effects. The anxiolytic effects are
achieved by promoting hippocampal neurogenesis, which is in turn promoted by
cannabinoids. n34. By finding that embryonic and adult rat hippocampal neural
stem/progenitor cells are immunoreactive for CB1 cannabinoid receptors, studies
demonstrate that cannabinoids can act on CB1 receptors to regulate neurogenesis. n35.
This is further corroborated by findings that cannabinoids promote proliferation, but not
differentiation, of embryonic hippocampal neural stem/progenitor cells via activation of
CB1 receptors combined with G proteins and ERK signaling. n36.

The anti-depressant and anxiolytic effects of cannabis are important as anxiety

and depression are frequent symptoms of PTSD and can be very debilitating. n37. It is
well-founded that cannabis and its major psychoactive component, (-)-trans-Δ9-
tetrahydrocannabinol, have profound effects on mood and can modulate anxiety and
mood states. n38. Thus, stimulating the endogenous cannabinoid system with natural
cannabinoids could be a major therapeutic target for the treatment of anxiety-related and
mood disorders. n39. In a study that looked at treating anxiety with cannabinoids,
blocking the CB1 receptor resulted in the rats having more fear, demonstrating that
modulation may be useful treatment for blocking fear, as seen in the blockade mice. n40.
These results indicate that the endocannabinoid system can be modulated to enhance
emotional learning and that endocannabinoid modulators may be therapeutically useful
for exposure based psychotherapies such as those used to treat PTSD and other anxiety
disorders. n41.

Based on its efficacy alone, cannabis should be considered an acceptable

treatment for PTSD. As Dr. Mikuriya said “Cannabis relieves pain, enables sleep,
normalizes gastrointestinal function and restores peristalsis. Fortified by improved
digestion and adequate rest, the patient can resist being overwhelmed by triggering
stimuli. There is no other psychotherapeutic drug with these synergistic and
complementary effects.” n42. Dr. Mikuriya also emphasizes that cannabis can relieve
many other symptoms of PTSD such as physical pain, fatigue, and sleep deficit.
Furthermore, restorative exercise and diet are requisite components of PTSD treatment
and depression treatment, and cannabis, unlike some analgesics, sedatives, and
benzodiazepines, does not leave the patient too immobile to exercise. n43.
III. PTSD and substance abuse

Many PTSD patients have poor responses to psychotherapy and often turn to
alcohol and drugs. n44. Moreover, many suffer from chronic pain and become addicted to
opiate pain medications. n45. Due to continuous problems such as depression, anxiety,
secondary alcoholism, and substance abuse that PSTD patients suffer from and the
numerous poor responses to pharmacological and psychological treatments, alternative
treatments such as cannabis are imperative.

While many studies, and many State Departments of Health, cite cannabis use as
substance abuse in PTSD patients, they ignore the positive effects of cannabis on the
brain and the reality that patients may not be abusing cannabis, but using it as an
alternative, effective treatment. Abuse can occur with any drug, including medically
prescribed Oxycontin or Vicodin as well as an over the counter drug like Tylenol. But the
possibility that these drugs can be abused does not make them illegal. The possibility that
some people might abuse cannabis should not make it illegal, when, like these other
drugs, it is scientifically proven to effectively treat a condition. In fact, “it is generally
appreciated that the use of cannabinoids is related to their positive modulatory effects on
brain-rewarding processes along with their ability to positively influence emotional states
and remove stress responses.” n46.

The differing effects of cannabis and other drugs of abuse on the brain highlight
the difference between using a drug as an effective treatment versus substance abuse.
Chronic administration of the major drugs of abuse including opiates, alcohol, nicotine,
and cocaine has been reported to suppress hippocampal neurogenesis in rats. n47. Unlike
these major drugs that inhibit neurogenesis, studies demonstrate that cannabis promotes
hippocampal neurogenesis. n48. This suggests a role of hippocampal neurogenesis in the
initiation, maintenance, and treatment of drug addiction.

The specific effect of the cannabinoid system on the fear response is significant
and suggests the potential for long-term relief. n49. Current acceptable treatments such as
behavior therapy, on the other hand, are ineffective for many. While behavior therapy for
human anxiety disorders is often effective, extinction-like treatments require repeated cue
exposures and are vulnerable to reversal by a number of environmental factors,
particularly stress. n50. Thus, cannabis has the potential to be an effective alternative to
often-ineffective behavior therapy and extinction treatment. n51.

The ineffectiveness of currently acceptable treatments leads to substance abuse.

Patients unable to find relief seek it elsewhere, with substances that are not regulated or
monitored by a physician. Moreover, psychiatrist-advised use of medical marijuana can
actually help PTSD patients reduce their alcohol intake. Marijuana addiction potential is
a fraction of that of alcohol (3% vs. 10%). n52. Dr. Christopher Ficthner, section chief for
PTSD at Hines V.A. Hospital in Illinois, explained that the use of medical cannabis can
reduce the physical and psychological harm for those who self-medicate with alcohol.
n53.

IV. New Mexico: Taking the lead in treating PTSD with cannabis.

New Mexico has taken the lead in explicitly allowing people with PTSD to have
access to marijuana under its medical marijuana law. PTSD accounts for more patients
than any other of the state’s 16 eligible debilitating conditions approved for medical
marijuana treatment. n54. After a review of the evidence of the effectiveness of
marijuana in treating PTSD, health professionals in New Mexico agreed that medical
marijuana could be beneficial for patients with PTSD. On the other hand, health officials
in Colorado are denying veterans and other patients suffering from PTSD a legitimate,
safe, treatment alternative.

The chief medical officer of the Colorado health department said, “There is no
evidence of efficacy of marijuana for treatment of PTSD in the medical literature.” n50.
This statement is outright false, inconsistent with evidence-based medicine and
demonstrates ignorance of the hundreds of medical studies on the efficacy of marijuana
for PTSD treatment. To deny the enormous body of medical literature is outrageous and
offensive to the suffering PTSD patients who are now the victims of the health
department’s ignorance. Dr. Eve Elting, a New Mexico physician, emphasized the
offensiveness of the Colorado Health Department when she said, “It’s bad enough they
have something that makes life so challenging. On top of that they’re discriminated
against, made to feel like they’re doing something wrong.” n55.

New Mexico is not alone in recognizing cannabis as an effective treatment for

PTSD. In Canada, the government pays for medical marijuana for their veterans,
acknowledging that for many, its is more effective than available alternatives, with fewer
side effects. n56. In Israel, the Ministry of Health is currently granting licenses for people
who have PTSD to use medical marijuana. n57

Even Croatia acknowledges cannabis as a treatment for PTSD. In 2009, Croatia’s

Supreme Court threw out a jail sentence given to a veteran who used marijuana for his
PTSD. n58. This ruling is extremely significant considering Croatia’s “zero tolerance”
drug policy. In its ruling, the court noted that “the defendant suffers from PTSD, and
marijuana relaxes him and helps him to overcome psychological problems.” n59.

V. Conclusion

To deny those with PTSD suffering from psychological trauma and terrifying
flashbacks access to a natural herb that is scientifically proven to provide them with relief
is simply outrageous. By allowing PTSD to be treated with medical marijuana, physicians
can help patients treat their condition with cannabis and assist the patient in using
cannabis in a manner that is safe and most effective for the particular patient. Physicians
can be re-assured that there is an ample body of medical literature that supports the
beneficial use of cannabinoids. Studies teach us that we have our own cannabinoid
receptors in our internal cannabinoids, and these should be modulated as they are proven
to reverse effects of stress and help with retention of aversive memories, promote
neurogenesis, and can reduce nightmares, fear, anxiety, mood disorders and other PTSD
symptoms. The importance of the endocannabinoid system and the large body of medical
literature supporting the beneficial use of cannabis should be acknowledged. Without the
acceptance of cannabis to treat PTSD, patients who cannot find relief with
pharmaceuticals and psychotherapy are forced to turn to the streets to have access to
cannabis. They are denied the very important role of the doctor in helping them treat their
condition. These patients will often turn to substance abuse and many turn to suicide.

We are sending millions of our citizens to Iraq and Afghanistan, and many are
coming back afflicted with PTSD and other psychological trauma. n60. We should give
them all of the tools available to regain their health. The enormous volume of scientific
research and data proves that the use of medical marijuana for PTSD is safe and effective.
To deny patients access to a treatment whose efficacy is well founded with scientific
evidence is callous and discriminatory at best.

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n55. Dan Frosch. States Differ on Marijuana for PTSD. The New York Times. 24
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n57. Marijuana/PTSD Protocol Drafted; MAPS Tries Again to Overcome PHS/NIDA

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