Using Cannabis Safely to Help Veterans with PTSD (Post-Traumatic Stress Disorder)

Helping Veterans With PTSD—How Big Is This Challenge?

In any given year, about 8 million people in the U.S. experience PTSD and even more remain undiagnosed. At particularly high risk are those charged to defend the country—military members exposed to a variety of traumatic events. It is an unfortunate consequence of war that those who enlist with such bravery are sometimes repaid with a debilitating disability that, if left untreated, can cast a shadow over the rest of their lives. Nearly 300,000 veterans deployed to Iraq and Afghanistan currently suffer from PTSD, and the estimated post-deployment PTSD prevalence in U.S. infantry averages 10–20%. Furthermore, the National Vietnam Veterans Readjustment Study estimated that nearly 30% of Vietnam veterans have had PTSD in their lifetime.

As a condition that is often accompanied by other psychiatric disorders, PTSD can severely inhibit a person’s ability to function in both occupational and social situations. Victims often struggle to operate during normal-day life, unable to hold down jobs or maintain relationships. As demonstrated by the bar chart below, dynamic models suggest that it can take more than 40 years for the country to recover from the psychiatric consequences of war. PTSD is a costly syndrome for veterans, their families, and society.

The best treatments for PTSD are still psychotherapies. While effective, they take time, and success often relies on a variety of human factors. Current medications for PTSD have limited efficacy as well as a multitude of dangerous side-effects. More research needs to be conducted to explore additional, safer solutions that work. 

Driven by a significant, unmet need for effective PTSD solutions, an overwhelming number of veterans turn to cannabis as an alternative to alcohol and other psychopharmaceuticals. They likely view it as more effective and with fewer accompanying, potentially dangerous, side-effects. Cannabis shows potential as a useful tool for battling PTSD; however, more research is needed to fully understand possible benefits, ascertain proper dosage guidelines, and prevent harmful reactions such as addiction.

What it is Like Living with PTSD

When dealing with PTSD, it is crucial to understand the severity of its symptoms and its scope of influence. At its core, PTSD is a mental health problem that can happen to anyone who experiences trauma or a life-threatening event. Examples of traumatic events include:

  • Combat and other military experiences.
  • Sexual or physical assault.
  • Serious accidents, such as a car wreck or drowning.
  • Natural disasters, including fires, tornados, hurricanes, floods, or earthquakes.
  • Other violent or threatening situations such as a terrorist attack or robbery.

While it is common to feel affected by a traumatic event, most people do not develop chronic PTSD. Though the incidents that result in PTSD may be unforeseeable, some factors increase the risk for chronic PTSD while others encourage successful recovery.

Recovery Factors

  • Strong support from friends and family.
  • Attending a support group.
  • Seeing help and treatment for symptoms.
  • Learning positive coping strategies.
  • Identifying as a survivor as opposed to a victim.
  • Hopeful and optimistic thinking.
  • General and specific self-efficacy.

Risks Factors

  • Permanent or temporarty injuries and/or pain.
  • Having little to no social support after the event.
  • Additional stress, such as the loss of a loved one, pain and injury or a loss of job of home.
  • A history of mental illness or substance abuse.
  • Childhood trauma.

 

Symptoms typically begin within three months of an incident, but sometimes they can take longer, even up to several years. Types of PTSD symptoms and their severity are expansive and manifest in diverse ways. Symptoms generally fall under four categories:

1

Intrusive thoughts

Otherwise known as “reliving the event,” intrusive thoughts involve unwelcome memories of the trauma. Examples of intrusive thoughts include:

Distressing dreams or nightmares.

Vivid flashbacks that make you feel like you are reliving the event.

Reliving the event when triggered by sights, sounds, or smells.

2

Avoidance

Trying to circumvent situations that remind you of the traumatic event or avoiding thoughts or feelings related to it. Changing or creating new habits or routines to accommodate these tendencies. Examples of avoidant behavior include:

Someone who was assaulted on a bus may avoid taking public transportation.
A combat veteran may avoid crowded places because of the perceived risk of being around so many people.
Victims of car accidents may avoid driving altogether.

3

Negative thoughts and feelings or changes in belief

Trauma can shake the foundation of people’s beliefs, leading them to change the way they think about themselves or others. The extent of these symptoms can differ greatly from person to person. Examples include:

Depressive symptoms, such as feeling sad or numb. Losing interest in things you used to enjoy.
Feeling like the world is dangerous and being unable to trust anyone.
Feelings of guilt or shame regarding the traumatic event.

4

Arousal or reactive symptoms

Also known as hyperarousal, these symptoms result in feeling jittery or on high alert. This category also encompasses mood swings, such as irritability and anger. Consequences of these symptoms include:

Difficulty sleeping or concentrating.
The onset of unhealthy activities such as smoking, abusing drugs and alcohol, or driving aggressively.
Being startled or surprised by loud noises or paranoia. This sometimes manifests in behavioral changes, such as wanting to have your back to a wall in a waiting room.

Most people experience some symptoms after a traumatic event. Therefore, the criteria for diagnosing PTSD requires the presence of all four types of symptoms lasting for at least a month.

Personal Accounts of Battling PTSD

For those living with severe PTSD, every day can be a battle of its own. The following excerpts are from personal accounts of people struggling with PTSD and demonstrate its severe impact on mental and physical health.

I don't know what the trigger was, but it hit me hard. I went home one evening and all of sudden, I felt a tightness in my chest, it was hard to breathe, I felt closed in and panicky. I bolted out of bed thinking I was dying. I paced the room in the dark for hours before I exhausted myself. . . . When I close my eyes at night, sometimes I still see myself picking up the body parts of my Soldiers. I still see myself holding my Soldiers as they die in my arms on the battlefield. I still see the blood of Iraqi children splattered all over my uniform as they take their last breaths due to no fault of their own. In the quiet moments of the day, when I am with my family, I see the faces of all the wives, children, husbands, mothers and fathers whose lives I destroyed with the notifications I made.

Major Carlos C. Huerta, an American Soldier
Major Carlos C. Huerta, an American Soldier

I was young, beautiful, and talented, but unbeknownst to them, I was terrorized by an undiagnosed debilitating mental illness. Having been properly diagnosed with PTSD at age 35, I know that there is not one aspect of my life that has gone untouched by this mental illness. . . . For me, there was no safe place in the world, not even my home. . . . For months after the attack, I couldn't close my eyes without envisioning the face of my attacker. I suffered horrific flashbacks and nightmares. For four years after the attack, I was unable to sleep alone in my house. I obsessively checked windows, doors, and locks. By age 17, I'd suffered my first panic attack. Soon I became unable to leave my apartment for weeks at a time, ending my modeling career abruptly. This just became a way of life.

P.K. Philips, lives with PTSD triggered by several childhood traumas
P.K. Philips, lives with PTSD triggered by several childhood traumas

I started to suffer from nightmares and panic attacks. I used to hate being around smoke and people who were covered in fake blood. Even now, I refuse to use a certain exit at King's Cross station because it reminds me of that day. It broke me down very quickly. I found surviving was the hardest thing I ever had to do. Every day was a struggle, and sometimes still is, forcing myself to get out of bed when I have spent all night with nightmares is agonizing. I remember thinking, and I used to be ashamed of this, that living was the hardest thing. Sometimes, I thought that it would have been easier if I was killed that day.

Sitara, survivor of the 7/7/2005 London bombings
Sitara, survivor of the 7/7/2005 London bombings

To learn more about what it is like to live with PTSD visit AboutFace, a site produced by the U.S. Department of Veterans Affairs’s (VA) National Center for Posttraumatic Stress Disorder. Here, you can watch unscripted videos that feature the real stories of veterans, their family members, and VA clinicians.

Limitations of Current Pharmacotherapy Options in Treating Veterans with PTSD

Studies suggest that serotonin selective reuptake inhibitors (SSRIs) are effective in treating PTSD in civilians; however, two randomized clinical trials made up of veterans neglected to find that SSRIs were more effective than a placebo. The results suggest that veterans, in particular, may be less responsive to SSRIs. Furthermore, despite being the preferred medication for treating PTSD, SSRIs are no longer recommended as first-line medications due to lack of testing and an absence of positive results. Sertraline and paroxetine are the only medications approved for PTSD treatment by the FDA.

Other medications used to treat PTSD are considered “off label” and only have empirical support. Thus, they are often discouraged in the treatment of PTSD due to side-effects. For example, Nefazodone, despite being effective, can cause severe liver damage. Monoamine oxidase inhibitors (MAOIs) are typically only prescribed when other antidepressants fail to work because of their dangerous interactions with certain foods and drugs. Mood stabilizers also lack evidential benefit, and current evidence suggests that the harms outweigh the benefits for all atypical antipsychotics.

While efficacy is debatable, it is worth noting that medications merely reduce symptoms, rather than eliminating them. For detailed information on medications used for PTSD, check out the VA’s Clinician’s Guide to Medications for PTSD.

Trends of Substance and Cannabis Use in the Military

Though accounts of psychological symptoms caused by military trauma date back to ancient times, links between the events of war and post-military life were not officially established until 1980. Considering the paralyzing effect of some PTSD symptoms and the lack of effective medicines available, it is not surprising that veterans use substances to cope. Individuals with PTSD are 2–4 times more likely to have a substance disorder (SUD). Among those, cannabis use disorder (CUD) has become the most commonly diagnosed in veterans, as exhibited by the bar chart below.

Similar to general population trends, cannabis use and addiction has been increasing in the military. In 2002, only about 13% of veterans with PTSD had a co-occurring marijuana addiction. By 2014, that percentage rose to 22.7% and will likely continue in that direction.

One possible reason why veterans commonly turn to cannabis is if they think their symptoms will go away over time. They may feel like all they need is a temporary reprieve until their symptoms resolve themselves. Unfortunately, PTSD does not improve when left untreated and may even get worse. Symptoms that feel manageable in the moment may intensify over time or become more numerous.

Studies have found that the severity of PTSD symptoms is linked to cannabis use and CUD in veterans. The more severe the PTSD is, the more likely someone is to turn to cannabis and also to abuse it. This poses complications, as those who may need it the most are also at a higher risk for CUD.

Expert Interview - Psychologist & Former Instructor for Harvard University

Stephen Willis, Ph.D.

Dr. Willis is a consultant, coach, and facilitator to Fortune 500 companies, startups, and nonprofits. He is a former instructor for Harvard University and a psychologist for people suffering from PTSD and trauma from war times. He is also a member of the American Psychological Association and its Society of Consulting Psychology.

Stephen Willis, Ph.D.
Why is PTSD a condition that deserves attention? In what ways have you seen PTSD affect veterans?

In my opinion, the fact that PTSD symptoms are extremely distressing and emotionally painful for patients makes PTSD deserving of treatment. PTSD deteriorates every area of a patient’s life—work, family, and social relations. In addition to the misery that PTSD patients personally suffer, they also become a burden to society and unable to enjoy a meaningful life as productive contributors. 

During my 30-plus years of treating patients with PTSD one of the key difficulties that patients consistently bring to treatment is how to successfully transition to civilian life from military life. Many veterans suffering from PTSD find that the traumas, stresses, losses, and scars of military service have changed them to such an extent that they feel out of place and no longer able to adapt in the civilian world. Despite feeling relief from the ordeals of military life, they struggle to find an identity and role that enable them to fit in and prosper in civilian life. 

On the other hand, many veterans resent having to leave the military. They feel forced out because of medical injuries or mental health problems such as PTSD, and have an especially difficult time transitioning. In the civilian world, they struggle to find a similar sense of purpose, a commitment to a mission, and the camaraderie that they found in their military units. They fondly recall their fellow soldiers who always “had their backs,” while lamenting civilians who are only “out for themselves.” As much as they wish they could return to military service, their PTSD renders them unfit for duty. 

Patients desperate to forge a path to success in the seemingly strange civilian world find themselves stumbling over repetitive failures at school. Because of PTSD they get exhausted and unable to concentrate and drop out of college, and at other times professors and administrators insist that they leave because of problems they are causing in the classroom, such as being confrontative with other students and being disruptive over relatively minor annoyances. 

At work a combination of low frustration tolerance and inadequate social skills for dealing tactfully with other employees and supervisors causes PTSD veterans to quit, or get ostracized and fired, again for being inappropriately confrontive and disruptive. Because of the PTSD veterans’ difficulties at work and school they have a higher risk of homelessness, anti-social behavior, alcohol and drug abuse, and suicide. 

PTSD also adversely impacts anyone that PTSD patients are involved with such as spouses and intimate partners, children, and extended family. PTSD frequently destroys the ability to function as effective parents.  It robs patients of the essential capability to tolerate frustration, moderate their behavior, and exert good judgment under pressure. One of the issues that PTSD patients agonize most over and desperately seek help for is the repairing of severely damaged relationships with spouses and partners, and their children.

How effective are current PTSD solutions?

I started my career treating patients with PTSD from the Vietnam war and WWII survivors. Comparing treatments from back then to now, the advances are impressive. The biggest benefits are that treatments are quicker and more focused on the core PTSD symptoms, especially the Evidence-Based Treatments (EBT).

One of the biggest advances, in my opinion, is bringing the spouse or family of the patient into treatment as a front line treatment approach. Doing so recognizes both the extent to which PTSD damages relationships, and the extent to which constructive partner relationships can help improve PTSD. It is essential to work with troubled relationships in order to improve PTSD. Dysfunctional couple relationships are a major reason for PTSD patients getting stuck and unable to improve. 

Couples therapy is a powerful approach to working with PTSD. In my opinion, one of the most potent forces for getting PTSD patients fully engaged in treatment is that they care about their families and are concerned about the adverse impact they are having about their families. However, it sometimes takes an ultimatum from a partner before the PTSD patient actually goes for treatment.

Over the past 20 years, psychologists have demonstrated through research that trauma-focused psychotherapies are more helpful in the long run than medications. Trauma-focused psychotherapies provide lasting benefits and you don’t have to stay on them as is the case for medications. However, with patients who have severe PTSD, medications are often helpful and necessary to enable patients to just get through the day -- to sleep at night, reduce nightmares, reduce flashbacks, prevent explosive outbursts, and reduce anxiety.

What is one piece of advice that you would provide to veterans with PTSD out there?

People who suffer from PTSD should not give up hope of gaining a satisfying quality of life and satisfying relationships. It is never too late to obtain help. PTSD can be treated and improved regardless of how long a person has endured the symptoms and regardless of how severe the symptoms have become.

Can Cannabis Assist In Treating PTSD?

Numerous studies suggest possible benefits of using cannabis to treat PTSD, but results and conclusions are mostly incomplete or inconclusive. Marijuana’s classification as a Schedule 1 substance makes it difficult for researchers to gain access to medical cannabis and conduct exhaustive studies. Consequently, studies on the use of cannabis to treat PTSD are mainly anecdotal, lack statistical data, neglect to control confounding factors, or excessively rely on self-reports. Many studies are conducted as observational or with bias and serve as a foundation for further exploration rather than providing objective evidence or conclusions.

A report published by the National Academies of Sciences, Engineering and Medicine concluded the following:

  • 1

    There is no evidence to support or refute that cannabis use increases the risk of PTSD.

  • 2

    There is moderate evidence for an association between CUD and PTSD.

  • 3

    There is limited evidence for increased symptom severity among individuals with PTSD.

A recent 2019 study determined that there is “insufficient evidence to support the use of cannabinoids as a psychopharmacological treatment for PTSD,” but acknowledged that, due to significant clinical need, future research is warranted to weigh the harms and benefits. The study seemed mostly concerned with the push to adjust policy making regarding cannabis without proper evidence to attest to the benefits. The study emphasized that clinical effectiveness is presently hypothetical rather than disparaging the idea that cannabis can treat PTSD.

Considering the already dangerous side-effects of current psychopharmaceuticals, the comparatively minimal and less perilous side-effects of cannabis and an apparent urgency for PTSD solutions, veterans suffering from PTSD should strongly consider cannabis as part of their treatment program if their symptoms are severe or unresponsive to treatment.

CBD vs. THC

Though cannabis contains over 70 distinct compounds, valuable insights have been discovered regarding the prominent components, THC and CBD. To take advantage of THC, the primary psychoactive component of marijuana, growers have been developing new strains with increasing THC levels over the years. However, recent studies have been highlighting CBD, the most abundant and non-psychoactive compound, as the most beneficial for medicinal purposes.

While THC is associated with the “high” and “active” effects of marijuana, CBD may produce antipsychotic and anxiolytic effects that counteract THC’s harmful components. Additionally, CBD may be useful in modulating fear-related symptoms of PTSD, such as the creation and maintenance of traumatic memories. The administration of CBD products after a traumatic event could help deter fear-induced memory processing.

Possible Benefits of Treating PTSD With Cannabis

The ability of cannabis to influence the body’s endocannabinoid system may make it invaluable for managing three of the core components of PTSD: reexperiencing, avoidance and numbing, and hyperarousal. Preclinical evidence supports the notion that CBD is an effective treatment when administered acutely for symptoms such as:

  • Sleep disorders and disturbances.
  • Emotional regulation.
  • Stress tolerance. 

One study showed a greater than 75% reduction in CAPS symptom scores (a universal method of measuring PTSD) when patients used cannabis compared to when they did not. Another study reported that some patients benefited from reduced anxiety and insomnia and improved coping abilities. Additional findings suggest that cannabis may even be capable of preventing PTSD symptoms in the first place when administered shortly after a traumatic event. 

Cannabis-use is most helpful and least problematic for those using it for physical symptoms such as chronic pain. Individuals reported that cannabis was moderately to mostly beneficial, though less than half of those reported a reduction in corresponding symptoms.

We do have the potential, however, to do better than just treating symptoms of PTSD via activation of the cannabinoid receptors. With the right combination of extinction/habituation therapy and the judicious administration of a FAAH inhibitor like KDS-4103 we have the potential to actually cure many cases of PTSD.

Dr. Raphael Mechoulam, Ph.D.
Dr. Raphael Mechoulam, Ph.D.

Possible Dangers of Treating PTSD With Cannabis

Abusing marijuana can trigger predisposing conditions such as depression, anxiety, and psychosis. Though a traumatic event must trigger PTSD, other mental conditions can intensify the symptoms of PTSD. Following, as with opioids and alcohol, marijuana may provide temporary relief while worsening symptoms like depression and anxiety over time. Moreover, if the brain becomes dependent on a drug to balance its neurotransmitter chemistry, it could lead to a deficit of dopamine or serotonin.

A VA study corroborated that cannabis provides short-term relief with possible long-term, harmful side-effects. Veterans with PTSD have a greater availability of cannabinoid type I receptors in the brain, which cannabinoids from marijuana will artificially bind to. This provides short term alleviation of stress symptoms associated with PTSD, but long-term use may create tolerance, causing the receptors to require more marijuana to function.

In this observational study, initiating marijuana use after treatment was associated with worse PTSD symptoms, more violent behavior and alcohol use. Marijuana may actually worsen PTSD symptoms or nullify the benefits of specialized, intensive treatment.

Samuel Wilkinson, MD, Yale School of Medicine
Samuel Wilkinson, MD, Yale School of Medicine

Barriers and Advances In Treating PTSD With Cannabis

While policies regarding medical and recreational cannabis use have been changing at the state level, federal law has yet to adapt or make allowances. Federal constraints do more than simply prevent recreational use; rather, they keep patients, health care professionals, and policymakers in the dark. The general public and institutions alike lack the information and evidence regarding the risks and benefits of cannabis, that they need to make informed decisions. The federal government continues to enforce restrictive policies and regulations on research. The main obstacles for urgently needed research are:

  • Regulatory Barriers

    Investigators must go through a lengthy and complicated approval process before conducting research or studies. They must seek permission from a variety of federal, state, or local institutions, with layers of bureaucracy driven by the Schedule I categorization of cannabis.

  • Cannabis Supply

    Research cannabis is only available through the National Institute on Drug Abuse’s (NIDA) Drug Supply Program, which primarily focuses on the consequences of drug use and addiction. The NIDA is committed to ensuring public safety rather than pursuing research in potential applications.

  • Funding Limitations

    Without adequate financial support, it is difficult for researchers to conduct thorough or lengthy studies. In 2015, only 16.5 percent ($10,923,472) of the NIDA budget for cannabinoid research supported studies that explored the potential benefits of therapeutic cannabis use—despite growing evidence that cannabis may have curative properties.

The VA’s Formal Stance

The VA’s policy does not currently endorse the use of cannabis to treat PTSD and will not pay for medical marijuana prescriptions. VA clinicians may only prescribe medications that have been approved by the U.S. Food and Drug Administration (FDA) for medical use, which presently does not include most products that contain THC, CBD, or other cannabinoids. VA clinicians are also not allowed to recommend medical marijuana to their patients. 

You can, and are encouraged, to discuss the use of medical cannabis with your VA provider. Health care providers will record cannabis use in their medical records; however, records are confidential and protected under patient privacy and confidentiality laws and regulations. Most importantly, you will not be denied VA benefits because of marijuana use.

The VA Medical Cannabis Research Act of 2018 authorized the VA to conduct and support research on medical cannabis, including for veterans enrolled in the VA health care system with conditions such as chronic pain or PTSD, suggesting that current medical marijuana policies are subject to future developments.

First Ever Clinical Trial

Recent efforts have been made to advance our understanding of cannabis and its medical uses. The Multidisciplinary Association for Psychedelic Studies (MAPS) completed the first-ever clinical trial on smoking marijuana to combat veterans’ PTSD symptoms. The U.S. Public Health Service approved of the study in 2014, and after denying MAPS access to medical marijuana for developmental research for over 22 years, the Drug Enforcement Administration (DEA) announced their intention to grant licenses to additional marijuana growers for research. The study, which began in 2017, completed its treatment phase in January 2019, and the publication of the results is eagerly anticipated.

Resources for Veterans and Their Loved Ones

Dealing with the symptoms of PTSD can be challenging for victims and family members. The first step to recovery is seeking help—a little support can go a long way. Whether you are interested in cannabis treatment or alternative solutions, check out the links below for information and aid.

  • VA PTSD Treatment Programs

    All VA medical centers offer treatment for PTSD; however, you can search by state for programs dedicated explicitly to PTSD. VA services are provided to all veterans who:

    • Completed active military service in the Army, Navy, Air Force, Marines, or Coast Guard (or Merchant Marines during WWII).
    • Were discharged under other than dishonorable conditions.
    • Were National Guard members or Reservists who have completed a federal deployment to a combat zone
  • Veterans Crisis Line

    If you are a veteran in a crisis or concerned about a loved one who is, connect with the crisis line via phone call, online chat, or text to reach caring, qualified responders from the VA.

  • Treatment Decision Aid

    This decision aid helps you make important decisions regarding PTSD treatment. Along with basic information on PTSD, you can compare treatment options and take the next steps to find a provider.

  • Find a Therapist

    The VA’s informational page on finding a therapist, counselor, or mental health care provider who can help with recovery. Includes steps as well as ways to find a provider using the internet or by phone.

  • PTSD Coach

    This mobile phone application from the VA can help you learn about and manage PTSD symptoms.

  • Self-help and Coping

    Learn to deal with excessive stress levels after trauma and other self-help strategies.

The first thing a family member needs to think about is: this is not your fault. This is something that has happened to your [loved one] that they don’t always have control over... It is not something that you need to be ashamed of.

Florence Vaught, Wife of a Veteran with PTSD
Florence Vaught, Wife of a Veteran with PTSD

Resources for Medical Cannabis

Patients looking to try medical cannabis will have to look to non-government resources. Fortunately, there are reputable organizations that educate and help people gain access to medical cannabis. If you are interested in cannabis as a treatment for PTSD, check out the following resources.

Finding a Treatment Center Near You

The process of finding nearby treatment centers is made easy with the following interactive map, based on SAMHSA’s facility locator:

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