Gundersen: More research needed before approving marijuana for PTSD
Author: Doris C. Gundersen - October 11, 2016 - Updated: October 10, 2016
The Colorado Psychiatric Society’s mission is to promote excellence in psychiatric care. Quality medical care is based on evidence derived from well-designed clinical trials. We are concerned about the draft bill that would add Posttraumatic Stress Disorder (PTSD) and Acute Stress Disorder (ASD) to the list of debilitating conditions that are authorized to be treated with medical marijuana for three reasons: 1) the Colorado Constitution already specifies a process for adding conditions; 2) Colorado has approved and funded well-designed research on the safety and efficacy of treating PTSD with marijuana and we should wait for those results; and 3) there is considerable evidence associating marijuana with harm to children and adolescents, who would be eligible to use marijuana for PTSD symptoms if this bill becomes law.
The Colorado Constitution has a process in place for adding debilitating medical conditions such as PTSD and ASD to the list of medical diagnoses that are authorized to be treated with medical marijuana. Article XVIII, Section 14 (III) of the Colorado Constitution specifies certain illnesses as “debilitating conditions” and allows that other medical conditions may be added when “approved by the state health agency, pursuant to its rule making authority.” Accordingly, the responsibility for adding indications for the use of marijuana for medical purposes is the responsibility of the state health agency. The Board of Health rules for adding a condition to the medical marijuana registry state that the Board should conduct a thorough review of current research to help guide their decision. The first step after receiving a petition to add a condition to the list is to “conduct a search of the medical literature for peer-reviewed published literature of randomized controlled trials in humans concerning the use of marijuana for the condition that is the subject of the petition” (5 CCR 1006-2, Regulation 6, D (1)). The State Board of Health has rejected petitions to add PTSD to the registry four times.
We do know that most psychiatric complications and known negatives of using marijuana are related to THC and there is promising research on using CBD to treat anxiety, insomnia, fear, hypervigilance, flashbacks and nightmares. However, it is premature to add PTSD to the list of debilitating conditions since there is insufficient medical evidence that whole plant marijuana is an effective treatment for PTSD. We simply do not yet have high-quality, long-term data based on randomized controlled trials that can offer guidance on the effects of marijuana on PTSD outcomes. The Colorado General Assembly has approved and funded randomized controlled clinical trials on the topic and Colorado should wait for scientific evidence on safety and efficacy.[i] Proponents may argue that there are numerous anecdotal reports and some studies that suggest marijuana may help alleviate PTSD symptoms and we cannot afford to wait. However, the best published research we have to date makes the case for caution: an observational study from Veterans Affairs programs that spanned 20 years and had a large sample size showed veterans with PTSD who started using whole plant marijuana had worse outcomes in PTSD symptom severity and higher levels of violent behavior, which is concerning.[ii] Additionally, PTSD is frequently comorbid with Substance Use Disorders and using marijuana to treat PTSD creates the risk of causing a second diagnosis.[iii] There are proven alternative treatments available. Evidenced based studies have shown that a combination of psychopharmacology and CBT (Cognitive Behavior Therapy) with an exposure component is the gold standard for PTSD. In addition, other modalities have been studied and found to be helpful in improving symptoms of PTSD including DBT (Dialectical behavior therapy — which emphasizes development of cognitive coping skills), EMDR (Eye Movement Desensitization and Reprocessing) and group therapies.[iv]
Finally, we are concerned that children and adolescents would be eligible to use marijuana for PTSD symptoms if it is added to the list of debilitating conditions. The Colorado Child and Adolescent Psychiatric Society opposes this bill because there is considerable evidence associating marijuana with harm to children and adolescents, including a well documented increased risk of psychosis, depression and substance abuse. Published results raise concerns that marijuana may be toxic to brain development, and numerous studies show marijuana exposure during critical periods such as pregnancy, childhood, adolescence and early adulthood may exacerbate or hasten the onset of psychiatric disorders.[v]
We support improving access to evidenced-based treatments. We encourage continuing to fund research to determine if certain components, dosages and delivery mechanisms of marijuana lead to more effective PTSD treatment. Our mission is to promote excellence in psychiatric care and that means we have a responsibility to wait for the research results.
[i] See https://www.colorado.gov/pacific/cdphe/approved-medical-marijuana-research-grants and https://s3-us-wes
[ii] Wilkinson et al., (2015). Journal of Clinical Psychiatry, 76:1174-1180
[iii] Boden, M, Babson, K, et al, Posttraumatic Stress Disorder and Cannabis Use Characteristics among Military Veterans with Cannabis Dependence. The American Journal on Addictions. 22:277-284, 2013 and http://www.ptsd.va.gov/professional/cooccurring/marijuana_use_ptsd_veterans.asp
[iv] US Department of Veteran’s Affairs. Treatment of PTSD. http://www.ptsd.va.gov/public/treatment/therapy-med/treatment-ptsd.asp
[v] See http://www.aacap.org/aacap/policy_statements/2012/AACAP_Medical_Marijuana_Policy_Statement.aspx and
Volkow et al., (2014). Adverse Health Effects of Marijuana Use. NEJM 370:2219-2227