The Long-Term, Prospective, Therapeutic Impact of Cannabis on Post-Traumatic Stress Disorder

Characteristics of Cannabis and Opioid Users Among Older U.S. Veterans and Their Health Outcomes: A Longitudinal Perspective

Medical cannabis use among U.S. Veterans has continued to rise. However, data on cannabis use by older Veterans is generally less available. This study aims to understand the characteristics of older Veterans who enrolled in the Medical Cannabis Patient Program in Illinois and analyze their health outcomes and co-use of cannabis and opioids using longitudinal survey data. Overall, participants reported positive outcomes for pain, sleep, and emotional problems because of cannabis use in two survey periods. Approximately, 62% and 85% respondents reported no change in memory and falls, respectively, with only 3% and 1% reporting a negative outcome for the conditions in both surveys. About 20.4% of those who indicated cannabis use only in the initial survey started to co-use opioids in the follow-up survey, while 44.1% of those who indicated the use of both substances in the initial survey reported no longer using opioids in the follow-up survey. However, these changes were not statistically significant (α = 0.05 ) . The logistic regression showed that both clinical and contextual factors affected co-use. In conclusion, older U.S. Veterans may be using cannabis to alleviate their pain and other chronic conditions. More research is needed to understand the effect of cannabis use on reducing or substituting opioids.

Post-traumatic stress and future substance use outcomes: leveraging antecedent factors to stratify risk

Background

Post-traumatic stress disorder (PTSD) and substance use (tobacco, alcohol, and cannabis) are highly comorbid. Many factors affect this relationship, including sociodemographic and psychosocial characteristics, other prior traumas, and physical health. However, few prior studies have investigated this prospectively, examining new substance use and the extent to which a wide range of factors may modify the relationship to PTSD.

Methods

The Advancing Understanding of RecOvery afteR traumA (AURORA) study is a prospective cohort of adults presenting at emergency departments (N = 2,943). Participants self-reported PTSD symptoms and the frequency and quantity of tobacco, alcohol, and cannabis use at six total timepoints. We assessed the associations of PTSD and future substance use, lagged by one timepoint, using the Poisson generalized estimating equations. We also stratified by incident and prevalent substance use and generated causal forests to identify the most important effect modifiers of this relationship out of 128 potential variables.

Results

At baseline, 37.3% (N = 1,099) of participants reported likely PTSD. PTSD was associated with tobacco frequency (incidence rate ratio (IRR): 1.003, 95% CI: 1.00, 1.01, p = 0.02) and quantity (IRR: 1.01, 95% CI: 1.001, 1.01, p = 0.01), and alcohol frequency (IRR: 1.002, 95% CI: 1.00, 1.004, p = 0.03) and quantity (IRR: 1.003, 95% CI: 1.001, 1.01, p = 0.001), but not with cannabis use. There were slight differences in incident compared to prevalent tobacco frequency and quantity of use; prevalent tobacco frequency and quantity were associated with PTSD symptoms, while incident tobacco frequency and quantity were not. Using causal forests, lifetime worst use of cigarettes, overall self-rated physical health, and prior childhood trauma were major moderators of the relationship between PTSD symptoms and the three substances investigated.

Conclusion

PTSD symptoms were highly associated with tobacco and alcohol use, while the association with prospective cannabis use is not clear. Findings suggest that understanding the different risk stratification that occurs can aid in tailoring interventions to populations at greatest risk to best mitigate the comorbidity between PTSD symptoms and future substance use outcomes. We demonstrate that this is particularly salient for tobacco use and, to some extent, alcohol use, while cannabis is less likely to be impacted by PTSD symptoms across the strata.

Challenges and considerations for treating PTSD with medicinal cannabis: the Australian clinician's perspective

INTRODUCTION

Preclinical and experimental research have provided promising evidence that medicinal cannabis may be efficacious in the treatment of posttraumatic stress disorder (PTSD). However, implementation of medicinal cannabis into routine clinical therapies may not be straightforward.

AREAS COVERED

In this review, we describe some of the clinical, practical, and safety challenges that must be addressed for cannabis-based treatment of PTSD to be feasible in a real-world setting. These issues are especially prevalent if medicinal cannabis is to be combined with trauma-focused psychotherapy.

EXPERT OPINION

Future consideration of the clinical and practical considerations of cannabis use in PTSD therapy will be essential to both the efficacy and safety of the treatment protocols that are being developed. These issues include dose timing and titration, potential for addiction, product formulation, windows of intervention, and route of administration. In particular, exposure therapy for PTSD involves recall of intense emotions, and the interaction between cannabis use and reliving of trauma memories must be explored in terms of patient safety and impact on therapeutic outcomes.

Self-reported Medicinal Cannabis Use as an Alternative to Prescription and Over-the-counter Medication Use Among US Military Veterans

BACKGROUND

Mental and other physical health concerns and substance use disorder are common and co-occurring events experienced by US veterans. Treatment with medicinal cannabis is a potential alternative to unwanted medication use for veterans, but more clinical and epidemiologic research is needed to understand the risks and benefits.

METHODS

Data were collected from a cross-sectional, self-reported, anonymous survey asking US veterans about their health conditions, medical treatments, demographics, and medicinal cannabis use along with its self-reported effectiveness. In addition to descriptive statistics, logistic regression models were run to examine correlates of the use of cannabis as a substitution for prescription or over-the-counter medications.

FINDINGS

A total of 510 veterans of US military service participated in the survey, which was administered between March 3 and December 31, 2019. The participants reported experiencing a variety of mental and other physical health conditions. Primary health conditions reported included chronic pain (196; 38%), PTSD (131; 26%), anxiety (47; 9%), and depression (26; 5%). Most participants (343; 67%) reported using cannabis daily. Many reported using cannabis to reduce the use of over-the-counter medications (151; 30%) including antidepressants (130; 25%), anti-inflammatories (89; 17%), and other prescription medications. Additionally, 463 veterans (91% of respondents) reported that medical cannabis helped them to experience a greater quality of life and 105 (21%) reported using fewer opioids as a result of their medical cannabis use. Veterans who were Black, who were female, who served in active combat, and who were living with chronic pain were more likely to report a desire to reduce the number of prescription medications they were taking (odds ratios = 2.92, 2.29, 1.79, and 2.30, respectively). Women and individuals who used cannabis daily were more likely to report active use of cannabis to reduce prescription medication use (odds ratios = 3.05 and 2.26).

IMPLICATIONS

Medicinal cannabis use was reported to improve quality of life and reduce unwanted medication use by many of the study participants. The present findings indicate that medicinal cannabis can potentially play a harm-reduction role, helping veterans to use fewer pharmaceutical medications and other substances. Clinicians should be mindful of the potential associations between race, sex, and combat experience and the intentions for and frequency of medicinal cannabis use.

Online survey of medicinal cannabis users: Qualitative analysis of patient-level data

Aim: To characterize perceived benefits and challenges experienced by medicinal cannabis users.

Methods: An anonymous online survey collected demographics, health information, and open-ended responses from medicinal cannabis users regarding perceptions, motivations, and experience of treatment. Qualitative open-ended responses were thematically analyzed.

Results: Respondents (N = 808) were predominantly White (79%), female (63%), with a mean (SD) age of 38 (20). Two hundred eighty-four (35%) respondents provided data on a dependent family member (e.g., child; 22% of total sample). Most used cannabidiol (CBD)-dominant products (58%), primarily for neurological disorders (38%) or pain (25%). Primary motivations for medicinal cannabis use were based on beliefs that traditional treatments were ineffective and/or had intolerable side effects (51%), positive scientific or media portrayals of the safety/efficacy of cannabis as a therapeutic (29%), or preference for “natural” treatments over pharmaceuticals (21%). A majority of respondents (77%) attributed positive effects to the medicinal use of cannabis/cannabinoids. These included physical symptom improvements such as reduced pain (28%), improved sleep (18%), and seizure reduction (18%), and mental health improvements including reduced anxiety (22%) and improved mood (11%). Additionally, respondents reported reduced use of other medications (e.g., opioids) (12%), and improved quality of life (14%). Problems associated with use were cited by 41% of respondents, and included unwanted side effects (16%), lack of information or medical support (16%), prohibitive costs (12%), and legal concerns (10%).

Conclusion: Most participants reported benefits from cannabis use for a variety of conditions where traditional treatments were ineffective or unacceptable. Concerns regarding cannabis side effects, legality, lack of information, and cost were raised. Data indicate greater research and education on the safety and efficacy of medicinal cannabis/cannabinoid use is warranted.

Effects of Cannabis on PTSD Recovery: Review of the Literature and Clinical Insights

Purpose of Review

Individuals with posttraumatic stress disorder (PTSD) may use cannabis to reduce symptoms yet are also at risk for developing problematic use. This review outlines theories, summarizes recent empirical studies, and discusses clinical implications of cannabis use and PTSD recovery.

Recent Findings

Although naturalistic studies and open trials find a relationship between cannabinoids and PTSD symptom reduction, methodological limitations preclude definitive conclusions. The only randomized controlled trial to date found cannabis had no greater effect on PTSD symptoms than placebo.

Summary

Rigorous studies of the long-term impact of cannabis use on PTSD recovery are needed. Clinicians and researchers must weigh the potential therapeutic effect against the costs and risks associated with long-term cannabis use. Clinicians should consider all available PTSD treatment options, along with client level factors such as the function of cannabis use, motivation to change use, and the potential impact of cannabis on treatment engagement when making clinical recommendations.

Cannabis use among U.S. military veterans with subthreshold or threshold posttraumatic stress disorder: Psychiatric comorbidities, functioning, and strategies for coping with posttraumatic stress symptoms

Cannabis use is common among individuals with posttraumatic stress disorder (PTSD) symptoms, but its impact on psychiatric symptoms and functioning in this population is unclear. To clarify the clinical and functional correlates of cannabis use in individuals with PTSD symptoms, we analyzed data from the 2019-2020 National Health and Resilience in Veterans Study, a nationally representative survey of U.S. military veterans. Participants with current subthreshold or full PTSD (N = 608) reported on their past-6-month cannabis use and current psychiatric symptoms, functioning, treatment utilization, and PTSD symptom management strategies. Veterans with subthreshold/full PTSD who used cannabis more than weekly were more likely to screen positive for co-occurring depression, anxiety, and suicidal ideation than those who did not use cannabis, ORs = 3.4-3.8, or used cannabis less than weekly, ORs = 2.7-3.7. Veterans who used cannabis more than weekly also scored lower in cognitive functioning than veterans with no use, d = 0.25, or infrequent use, d = 0.71, and were substantially more likely to endorse avoidance coping strategies, ORs = 8.2-12.2, including substance use, OR = 4.4, and behavioral disengagement, ORs = 2.7-9.1, to manage PTSD symptoms. Despite more psychiatric and functional problems, veterans with frequent cannabis use were not more likely to engage in mental health treatment, ORs = 0.87-0.99. The results suggest enhanced cannabis use screening, interventions targeting risky use, and strategies promoting treatment engagement may help ameliorate more severe clinical presentations associated with frequent cannabis use among veterans with subthreshold/full PTSD.

Diverse therapeutic developments for post-traumatic stress disorder (PTSD) indicate common mechanisms of memory modulation

Post-traumatic stress disorder (PTSD), characterized by abnormally persistent and distressing memories, is a chronic debilitating condition in need of new treatment options. Current treatment guidelines recommend psychotherapy as first line management with only two drugs, sertraline and paroxetine, approved by U.S. Food and Drug Administration (FDA) for treatment of PTSD. These drugs have limited efficacy as they only reduce symptoms related to depression and anxiety without producing permanent remission. PTSD remains a significant public health problem with high morbidity and mortality requiring major advances in therapeutics. Early evidence has emerged for the beneficial effects of psychedelics particularly in combination with psychotherapy for management of PTSD, including psilocybin, MDMA, LSD, cannabinoids, ayahuasca and ketamine. MDMA and psilocybin reduce barrier to therapy by increasing trust between therapist and patient, thus allowing for modification of trauma related memories. Furthermore, research into the memory reconsolidation mechanisms has allowed for identification of various pharmacological targets to disrupt abnormally persistent memories. A number of pre-clinical and clinical studies have investigated novel and re-purposed pharmacological agents to disrupt fear memory in PTSD. Novel therapeutic approaches like neuropeptide Y, oxytocin, cannabinoids and neuroactive steroids have also shown potential for PTSD treatment. Here, we focus on the role of fear memory in the pathophysiology of PTSD and propose that many of these new therapeutic strategies produce benefits through the effect on fear memory. Evaluation of recent research findings suggests that while a number of drugs have shown promising results in preclinical studies and pilot clinical trials, the evidence from large scale clinical trials would be needed for these drugs to be incorporated in clinical practice.

Coping Motives Mediate the Association of Trauma History with Problematic Cannabis Use in Young Adult Medical Cannabis Patients and Non-Patient Cannabis Users

Background: Despite evidence of the contribution of childhood trauma to the development of problematic cannabis use, its mediating pathways are largely unknown. Given the link between cannabis motives with trauma and problematic cannabis use, motives of use may represent a construct through which trauma impacts problematic cannabis use. Methods: A sample of 339 medical cannabis patient and non-patient young adult users from the Los Angeles area were sampled at baseline and one year later. The current study examined the impact of childhood trauma on problematic use through a variety of cannabis use motives. Results: Controlling for age, socioeconomic status, perceived stress, and baseline problematic use, endorsing the use of cannabis to cope with distress at baseline uniquely mediated the associations between different childhood trauma types (e.g., physical abuse, neglect, sexual trauma) and problematic use one year later. Experience of any childhood trauma was positively associated with coping motives, whereas emotional and physical abuse were positively associated with pain motives, and sexual abuse was positively associated with sleep motives. Using cannabis for coping and increasing attention/focus were also positively associated with higher problematic use, whereas using cannabis for sleep was inversely associated with problematic use one year later. Conclusions: The motives of coping with distress and inattention may represent intermediate constructs through which trauma leads to later problematic cannabis use. Results highlight the need to clarify the pathways between health and non-health-oriented motives and cannabis use over time.

The Effects of Cannabinoids on Sleep

The use of cannabis products to help with sleep and various other medical conditions by the public has increased significantly in recent years. Withdrawal from cannabinoids can lead to sleep disturbance. Here, we describe a patient who developed significant insomnia leading to worsening anxiety, mood, and suicidal ideation in the setting of medical cannabis withdrawal, prompting presentation to the Emergency Department and inpatient admission. There is a limited evidence base for the use of cannabis products for sleep. We provide a comprehensive review evaluating the literature on the use of cannabis products on sleep, including an overview of cannabis and related psychoactive compounds, the current state of the law as it pertains to the prescribing and use of these substances, and potential side effects and drug interactions. We specifically discuss the impact of cannabis products on normal sleep and circadian sleep-wake rhythms, insomnia, excessive daytime sleepiness, sleep apnea, parasomnias, and restless legs syndrome. We also describe the effects of cannabis withdrawal on sleep and how this increases relapse to cannabis use. Most of the studies are observational but the few published randomized controlled trials are reviewed. Our comprehensive review of the effects of cannabis products on normal sleep and sleep disorders, relevant to primary care providers and other clinicians evaluating and treating patients who use these types of products, shows that cannabis products have minimal to no effects on sleep disorders and may have deleterious effects in some individuals. Further research examining the differential impact of the various types of cannabinoids that are currently available on each of these sleep disorders is required.

Translation of animal endocannabinoid models of PTSD mechanisms to humans: Where to next?

The endocannabinoid system is known to be involved in mechanisms relevant to PTSD aetiology and maintenance, though this understanding is mostly based on animal models of the disorder. Here we review how human paradigms can successfully translate animal findings to human subjects, with the view that substantially increased insight into the effect of endocannabinoid signalling on stress responding, emotional and intrusive memories, and fear extinction can be gained using modern paradigms and methods for assessing the state of the endocannabinoid system in PTSD.