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Abstract
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Let's face it: a lot of our patients use cannabis. A lot. And what we tell them about how to manage this in the face of their symptoms; their risk for psychosis, mood, and anxiety symptoms; and their overall health must come from a place of evidence so that we can be partners in their decision making. The medicalization (not to mention the legalization) of marijuana has arrived before the evidence for its effectiveness and safety, and our patients will make up their own minds, especially when they initiate or continue marijuana or other cannabinoid use in the midst of (or instead of) our treatment of them for posttraumatic stress disorder (PTSD). We need to understand whether there are benefits to cannabis use and, importantly, whether the harms we fear about its use are measured so that we can communicate in a truly informed way to our patients about how they might proceed.
There are clearly strong opinions about this. The Department of Veterans Affairs (VA)/Department of Defense (DoD) Clinical Practice Guidelines for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder1 conclude, "We recommend against cannabis or cannabis derivatives for the treatment of PTSD," with a "Strong against" strength of recommendation, due to the lack of evidence for their efficacy, known adverse side effects, and associated risks (including an association with worsening symptoms of PTSD and increased violence).1,2 That is a pretty definitive statement. It's understandable that it would be made, too, given that an estimated 28.9% of Veterans with PTSD have used cannabis in the prior 6 months, while the rate of current cannabis use disorder in Veterans with co-occurring PTSD is estimated at 12.1%.3 How do we square all these things? Namely, that cannabis use is widespread in people with PTSD, that apparent risks for a use disorder may be high, and that no benefit for cannabis for PTSD has been established. Justyne Rodas and colleagues at the University of Toronto have analyzed data in a systematic review4 of studies of cannabinoids in PTSD and may have arrived at a more granular and nuanced understanding of how cannabis use in PTSD might be understood, giving the clinician perhaps just a bit more information to share with their patients around the use of cannabis when symptoms of PTSD are present.
Their paper, in this issue of JCP, is a thorough review of the available literature on the use of cannabinoids, examining not only clinical trials, but epidemiologic and other studies, too. The data available--especially given the widespread use of cannabinoids--are unfortunately paltry, limited in large part by the regulatory burden put on the use of non-prescription cannabis and cannabinoids (the drug is a DEA Schedule I drug in the United States, meaning that it has "no currently accepted medical use and a high potential for abuse") but also due to the difficulty in standardizing the study of products that have essentially no regulatory control over their tetrahydrocannabinol (THC) content and because it can is delivered through different means (eg, smoked, vaporized, ingested). Because of this, there are few outcome data that could be studied in a meta-analysis, and the authors must instead rely on a narrative review; their findings are nonetheless of interest. To summarize, among the 10 studies they found that investigated the impact of cannabis on overall PTSD symptoms within a group not diagnosed with cannabis use disorder (CUD), half of them indicated potential positive outcomes linked to cannabis use, while the other half found no discernible effects or even an exacerbation of symptoms. Additionally, in the case of cluster B- and E-related PTSD symptoms among individuals without CUD, 4 studies reported potential benefits associated with cannabis use. It is important to note, however, that when examining individuals who both were using cannabis and had a coexisting diagnosis of PTSD and CUD, all 3 studies reported a heightened risk of worsening overall symptoms, and 1 observational study of Veterans admitted to a specialty VA PTSD program found that starting cannabis use after treatment was associated with more severe PTSD symptoms, more violent behavior, and alcohol use (although the causality of the relationship could not be established)
Language: en |