Attendees, including Champlain Valley Dispensary patients and employees, listen to a lecture about Cannabis and PTSD by Dr. Marcel Bonn-Miller, Ph.D at CVD Facilities in Milton, Vermont on Friday, October 7, 2016. by Eli Harrington for Heady Vermont.

Attendees, including Champlain Valley Dispensary patients and employees, listen to a lecture about Cannabis and PTSD by Dr. Marcel Bonn-Miller, Ph.D at CVD Facilities in Milton, Vermont on Friday, October 7, 2016. by Eli Harrington for Heady Vermont.

MILTON, Vt. — Inside the nondescript industrial building that houses the primary growing facility and headquarters of the state’s largest medical marijuana dispensary, nearly 40 Vermont medical marijuana patients and dispensary employees gathered to hear Dr. Marcel Bonn-Miller, Ph.D, one of the nation’s top cannabis researchers at the U.S. Department of Veterans Affairs (VA) discuss the interactions between cannabis and PTSD, one of the most important and widely-discussed topics in medical marijuana.

Event Flier via CVD

Event Flier via Champlain Valley Dispensary

The educational event was coordinated by Champlain Valley Dispensary (CVD), the largest medical marijuana dispensary in Vermont, based in Burlington. The event included an interactive presentation and Q&A session and was open to dispensary staff and registered CVD medical marijuana patients, who represented about a third of the nearly 40 total attendees.

CVD Retail Operations Manager Chris Copley noted that as the dispensary grows and matures as a business, they’re starting to focus more on educational outreach and opportunities for patients to connect with each other and that PTSD is a frequent topic of discussion.

“We had been doing research about PTSD, which isn’t presently a qualifying conditions. We feel that’s something that possibly we could advocate for in the future, so it was kind of timely. And we do have a lot of veteran patients who do bring this up with us, so for all of the dispensary staff and for everyone to learn more about the research, it made sense.”

When examining the specific intersections of cannabis and PTSD, Dr. Marcel Bonn-Miller, Ph.D, is perhaps the most qualified researcher in the United States. Based at the VA offices in Palo Alto, California as well as the University of Pennsylvania, his full job title is, “Research Health Science Specialist at the Center of Excellence in Substance Abuse Treatment and Education (CESATE), National Center for PTSD (NCPTSD), and Center for Innovation to Implementation (Ci2i),  at the Veterans Affairs (VA) Palo Alto Health Care System & Adjunct Assistant Professor in the Department of Psychiatry at the University of Pennsylvania Perelman School of Medicine.

Cannabis and the Military

During the Vietnam War, many Americans were introduced to cannabis for the first time, and while some brought back a habit and taste for smoking the Southeast Asian Sensi, many more returned with PTSD and physical injuries. According to the US Department of Veterans Affairs, the rates of PTSD for Vietnam veterans might have been as high as 30%, double the rates of Operation Iraqi Freedom and Operation Enduring Freedom, respectively. While the notion of war causing mental anguish is hardly a contemporary one (see: “All is Quiet on the Western Front”), those Vietnam War veterans were the first subjects of serious medical and psychological research into PTSD and trauma.

During and immediately after Vietnam, the cultural distance between the crew-cut military establishment and the long-haired cannabis user was about as close as the Haight-Ashbury was to Ho Chi Minh City. Much of that changed thanks to Jack Herer, the author of the seminal pro-legalization book, “The Emperor Wears No Clothes” and one of the most influential and impactful cannabis advocates up until his passing in 2010. While Herer is already a legend in the cannabis community, many don’t realize that Herer himself was a veteran of the Korean War.

In 2011, the VA changed its policy to ensure that veterans using medical marijuana in legal states aren’t being punished, however due to the federal status of cannabis as a Schedule one drug (“with no medicinal purpose”) things are still complicated.

At the federal level, progress is being made, but it’s slow (at best): VA doctors cannot give recommendations for medical marijuana cards even in states where it is legal; however, in May 2016 the House passed an Amendment to a spending bill that would grant easier legal access for veterans.

Grassroots Vets Groups

While the changes at the VA might be slow due to federal restrictions, Bonn-Miller himself affirmed that much of the successful lobbying has been from veterans and veterans groups.

“There are a lot of groups, including a growing number of veteran organizations, that really are strongly advocating for cannabis legislation because they’ve had positive experiences with it. I think that a lot of the push for including PTSD in other states is from such veterans groups.”

One of those veterans groups is the New England Veterans Alliance (NEVA), a group started by Derek Cloutier and Sean Judge. Cloutier and Judge were both in Iraq and are both combat veterans having served in the Marines and Army, respectively. Cloutier is from Lowell, Massachusetts and suffers from PTSD and chronic pain and is a registered patient in Massachusetts.

Cloutier says that the group came together organically as he and Judge started organizing get togethers where vets would discuss, among other things, medical marijuana. Eventually they started bringing vets to doctors to get medical marijuana cards and hosting larger gatherings and organizing groups of veterans to testify to legislators and speak at events around New England.  For the vets that attend the sessions, the therapeutic health benefits come from sharing both the herbs and the verbs. As Cloutier says:

“We have these group sessions or get togethers where we meet with fellow vets where we can socially medicate and educate each other on what works or not for us. We also talk about our lives or service and it gives veterans or patients an outlet to talk and open up about things they normally wouldn’t talk about. Cannabis helps them overcome whatever anxiety or depression from PTSD that they may be dealing with to be able to have that therapeutic experience with other veterans that understand.”

Now, Cloutier says that the group is expanding (any interested veterans should reach out to them via facebook) and organizing into an actual nonprofit. He personally testifies to the power of cannabis in treating PTSD, chronic pain and anxiety. “It helps my brain calm down and instead of racing between four thousand things, I can think about four. I’m able to focus and concentrate and just feel more in tune with life and more engaged.”

At the national level, Tom Angell of Marijuana.com first reported that in early September of this year, the American Legion, the nation’s largest military veterans organization (over 2.4 million), officially called on congress to reschedule cannabis to “at minimum, will recognize cannabis as a drug with potential medical value.”

Is PTSD A Qualifying Condition in Your State?

Presently, PTSD is considered a qualifying condition for medical marijuana in 17 states, the District of Columbia and Guam with Rhode Island being the latest state to add it in 2016, joining Ohio, New Jersey and Pennsylvania.

In Massachusetts, PTSD is not explicitly listed as a qualifying condition, but in the Bay State (and most others), doctors have discretion to prescribe or recommend medical marijuana for other conditions. In Maine, PTSD has been a qualifying condition since 2010 (fun fact: Maine also has the highest population percentage of registered medical marijuana patients in New England) and in Rhode Island, it just became a qualifying condition in 2016. In Vermont and New Hampshire, physicians don’t have the discretion to recommend or prescribe medical marijuana (although some would appreciate that option over the current system) and only sign a document confirming the would-be patient has a qualifying condition.

New Mexico was the first state to allow PTSD as a qualifying condition and in 2014, researchers there published initial findings of a three-year retrospective study of 80 medical marijuana users with PTSD symptoms. Among other things, those results showed, “Greater than 75% reduction in Clinician Administered Post-Traumatic Scale (CAPS) symptom scores were reported when patients were using cannabis compared to when they were not.”

Existing Research and the “Gold Standard” of Studies

While not involved in New Mexico, Marcel Bonn-Miller has completed numerous studies on a similar scale mostly in California. He, along with the Multidisciplinary Associations for Psychedelic Studies (MAPS), Dr. Sue Sisley, and Dr. Ryan Vandrey at Johns Hopkins Medical Center, have received the go-ahead to start registering veterans for the first-ever randomized placebo-controlled trial of cannabis as a treatment for PTSD.

This controlled study will work with 76 veterans with unremitting PTSD symptoms and will take place in Baltimore and Phoenix. As the Daily Pennsylvanian reported in January 2015, the controlled study will track the Veteran participants using four different strains: one that is high in THC and low in CBD, one that is high in CBD and low in THC, one that is an even proportion of both, and a placebo. Because they will be administering cannabis to patients, their product must come from the Marijuana Research Project stash at the University of Mississippi, the only DEA and FDA-approved source of research cannabis.

When asked by an audience member about the intake method of the studies, Bonn-Miller confirmed that the PTSD test subjects will be smoking the cannabis, explaining that “smoking is the quickest and most direct delivery system for getting cannabis into the system, and importantly, smoking effects also wear off faster, so if there is a negative experience or response, it’s over quicker.”

The controlled study is one of nine total grants funded by the Colorado Department of Public Health and Environment, an allocation of roughly $9 million over the course of five years. As the Daily Pennsylvanian first reported, Dr. Bonn-Miller leads the largest two of the nine studies thanks to a $2.15M and 1.18M grants from the state of Colorado.

Typically, the funding to do these kind of large-scale studies on the therapeutics of drugs comes from pharmaceutical companies seeking FDA approval, so a state funding large research projects is rare enough, and funding them with cannabis tax revenues is truly ground-breaking.

As one of the lead researchers receiving the funds to carry out the studies, Dr. Bonn-Miller obviously appreciates the opportunity to advance the scientific understanding of the role of cannabis in PTSD. As someone knowledgeable about specific state and federal policies, he also agrees that Colorado’s model of using cannabis revenues to fund scientific research is one that other states should copy and codify as they decide how to allocate future cannabis revenues.

“I think that it’s one of the most important things to consider, to be honest. I really think that each state should be giving money back to research, not only because they’re profiting from applications and sales, but because we need to be able to give accurate and good medical advice to patients based on research, which we just don’t have right now.”

Dr. Sam Russo, N.D. is a Burlington-based naturopathic physician and past president of the Vermont Association of Naturopathic Physicians as well as current scientific editor for Better Nutrition Magazine. Russo attended the event and said that one of the main takeaways for him was that more scientific research on cannabis is needed, but that it’s positive to see it moving forward. Vermont-licensed naturopaths like Dr. Russo are allowed to sign Vermont Marijuana Registry forms for medical marijuana patients, provided that would-be patient has a bona-fide medical relationship with the MD/PA/APRN/ND and a qualifying condition. Dr. Russo agrees with Bonn-Miller that the funding model for the PTSD research makes sense:

“If some of the medical marijuana laws, and even the recreational marijuana laws, include a requirement to divert a portion of profit and taxes toward research. I know in Colorado they’ve earmarked portions to taxes from the sale of recreational marijuana to public education, so I think that is an area that’s been utilized efficiently.”

In addition to the controlled study, Bonn-Miller will also lead a larger, and in some ways, even more interesting PTSD study that will take place in Denver and is observational, rather than strictly experimental. That study consists of 150 participants with PTSD, half of whom already use cannabis and will be using their own that they obtain from a dispensary, and half of whom are non-users who will be matched with the other half and tracked.

Rather than FDA herb from Mississippi, the PTSD medical marijuana patients in the larger Denver study will be able to continue using whatever kind of medical cannabis (including products like edibles and oils) are available to them. This means that researchers will have a much larger and more diverse sample size and set of experiences from which to collect scientific information about effective treatments for PTSD, which until now has only been shared between fellow patients on message boards, at meet-ups like those of the New England Veterans Alliance, and from bud-tenders over the counter at dispensaries in legal states.

Treating PTSD With Cannabis – Is CBD the Key?

As Bonn-Miller shared with the audience back in Vermont in early October, when existing medical marijuana patients are asked about why they use cannabis, one of the most frequent responses given is that it’s for ‘coping’. While ‘coping’ is certainly also necessary for physical pain, that also covers people coping from emotional trauma, stress, and anxiety–irregardless of the source.

When having a serious conversation about cannabis with new medical marijuana patients (and most members of the public), one of the first concepts to explain is that the cannabis plant has a number of different compounds, including cannabinoids and terpenes. Most people are familiar with delta-9-Tetrahydrocannabinol, or THC, which is a compound that causes a psychoactive reaction and gives users a ‘high’ feeling, but the public’s understanding of other cannabinoids, such as Cannabidiol (or CBD), is still evolving.

In legal terms, this balance of THC and CBD compounds is what differentiates and defines legal “hemp”. If a cannabis plant has over .3% THC, it’s marijuana (and federally illegal); however, if a plant has less than .3%THC, it can have any other combination of cannabinoids (allowed by the natural genetic parameters of the plant specie), including high levels of CBD, and be legal.

image via hempoilfacts.com ~ read more about the Endocannabinoid System

Most who have heard about CBD have heard it in the context of using a (trademarked) cannabis oil mixture called “Charlotte’s Web” to treat children with epilepsy and other neurological disorders, such as Dravet Syndrome. Other segments of the population are starting to encounter this legal cannabinoid thanks to the increase in popularity of CBD in natural health products (there’s even CBD for dog health). So whether it’s for medical marijuana patients, children, fit hippies, or dogs–how do you describe the effects of CBD if it’s not getting you ‘high’ like THC?

When the expert, Dr. Bonn-Miller, was asked how he describes the difference, especially to those unfamiliar with cannabis, he used a see-saw analogy to compare THC and CBD:

“Basically the way that I talk about CBD is that it is like a see-saw, it’s the opposite of THC–everything that THC does, CBD does the opposite. That’s kind of a rudimentary way of talking about it, but it’s a place to start. There are so many different things that CBD has been implicated in, in terms of treatment, many of which can be made worse by THC.”

Mary's Medicinals sells a

Mary’s Medicinals sells a “Rescue Tonic” that contains a high dose of CBD which is used to counteract high doses of THC and ‘rescue’ users from bad trips. In Vermont it’s available at the CVD Shop in Burlington

Building on the see-saw relationship between CBD and THC, one of the more popular new products being sold legally in many states are high-CBD ‘rescue’ products that are designed to counteract high doses of THC for users who get too ‘high’ on THC and feel adverse effects, such as anxiety.

A Burlington bud-tender agreed that describing CBD as the opposite of THC is a good start, but noted that the difference can also be described as THC being more mental and CBD causing more physical and internal effects. “I wouldn’t say that CBD gets you down, so it’s not a perfect opposite–I think it’s also useful to describe CBD as getting you ‘balanced and rooted’. 

Chris Copley, the Retail Operations Manager at the Champlain Valley Dispensary–which carries the Mary’s Medicinals Rescue Tonic in it’s public CVD Shop on the Burlington Bikepath–agreed that the legality of CBD is allowing for everyone, whether medical marijuana patients or not, to experience the potential of CBD products.

“With CBD, I think it’s a really exciting horizon and we’re proud of the state of Vermont for allowing us to do what we’re doing with CBD products and I think the horizon is still way in front of us in terms of what the public knowledge base and acceptance will be, and a lot of it is education and a lot of it is experimentation for people who try it and say, ‘wow, these products actually do work for me’…The CBD side of medical marijuana is really interesting, especially to kind of look at it the same way the speaker is looking at it as almost something separate because the effects of CBD and the benefits.”

CBD does work on your neurological system as well–in fact it’s also being studied as a treatment for those with post-concussion syndrome and brain trauma as it has been shown to help build and repair neurological pathways. Bonn-Miller noted that he’s also working with current and former NFL and NHL players who have experienced head trauma. “Players have banded together to fund and advocate research in this area so we can document what’s going on, because they have experienced benefits from CBD in terms of inflammation and head trauma. If you look at a guy who’s been playing on the line in the NFL for ten years, he looks very similar to someone who’s been in an IED blast in Afghanistan. This is more than just about sports.”

Specific to PTSD, Bonn-Miller and his colleagues have observed and documented that there are specific conditions in the brains of those suffering from PTSD which make them more receptive to cannabinoids:

“Research has consistently demonstrated that the human endocannabinoid system plays a significant role in PTSD. People with PTSD have greater availability of cannabinoid type 1 (CB1) receptors as compared to trauma-exposed or healthy controls. As a result, marijuana use by individuals with PTSD may result in short-term reduction of PTSD symptoms.”

Use vs. Abuse

As Bonn-Miller is also careful to point out, and as he discussed in his Vermont presentation extensively, there are decades of anecdotal evidence showing potential positive results; however, there is also evidence that those suffering from PTSD might also be more susceptible to substance use disorders, and that cannabis use disorder has spiked in the past decade. In the same VA report quoted above about the increased availability of cannabinoid receptors in PTSD sufferers, Bonn-Miller and his colleague also note the adverse effects of cannabis on those with PTSD.

“However, data suggest that continued use of marijuana among individuals with PTSD may lead to a number of negative consequences, including marijuana tolerance (via reductions in CB1 receptor density and/or efficiency) and addiction. Though recent work has shown that CB1 receptors may return after periods of marijuana abstinence, individuals with PTSD may have particular difficulty quitting.”

When discussing the adverse effects, there were plenty of comments from the audience about qualifiers (“what’s worse, cannabis use disorder or opiate addiction?”) and about the severity of effects. Bonn-Miller acknowledged that for cannabis, addiction is more often emotional symptoms rather than physical. He also noted that it’s more frequently the very high levels of THC that have had the worst effects in terms of addiction and withdrawal.

During the Q&A at the presentation at CVD in Vermont, Bonn-Miller was asked about clinical recommendations for medical marijuana staff and medical professionals to keep in mind when talking about PTSD, and he reaffirmed the importance of quality control and tracking clinical outcomes.

He also advised both the bud-tenders and patients in attendance to, “forget strain names, forget whether it’s sativa or indica and first think about the cannabinoid content. As best you can, know what cannabinoids are in the plant and the symptoms being treated.”

Overall, Bonn-Miller also feels strongly that standardized testing and basic product safety are two huge issues that can’t be ignored. “If something is a few THC or CBD percentage points off for a ‘recreational’ user, it’s one thing, but you really can’t mess around with the medicinal side. There are also bigger health implications when you start getting into growers that use pesticide or have product with mold. We need to make sure the product is consistent, and we’re not even close I’m sorry to say.”

What’s Next

In every way, the understanding of cannabis continues to evolve as an increasing number of cannabis users are adding anecdotal evidence to the larger body of evidence and knowledge, while legal purchases in places like Colorado are directly funding the scientific studies that researchers (and many legislators) consider to be the missing ‘gold standards’.

Ultimately, the federal classification of cannabis as a schedule 1 substance hampers research, the transportation of medical marijuana products from one state to another, and creates a patchwork of different regulations and practices that vary from state to state. While the Internet has allowed information to spread faster than ever, without at least the rescheduling that the American Legion and others have called for, those that interact with and rely upon, the federal government (such as veterans, farmers, and those receiving social security benefits) are most disadvantaged by the Schedule 1 status.

2016 is regarded by many as a national legalization tipping point with five additional states–including California–poised to vote on various referendums in November. However, even with the future publishing of critical research like that being carried out by Dr. Marcel Bonn-Miller, Dr. Ryan Vandrey and others, grassroots organizations such as NEVA, the networks of patients, caregivers, and bud-tenders, and the experiences they share with each other will continue to play the central role in helping medical marijuana patients learn about new treatment techniques and support each other.

When it comes to PTSD, in general, there is still much to be learned, especially in studying PTSD in women, who are more than twice as likely as men to experience PTSD as a result of a traumatic incident. Because veterans are easier to study than say, victims of domestic violence or sexual assault, that research is more difficult to conduct, but with increasing cannabis revenues and a strong new precedent from Colorado for funding scientific research, there are new opportunities.

In terms of medical cannabis and the treatment of PTSD, the present foundational understanding comes from anecdotal and observational, not experimental evidence. Furthermore, there is some scientific evidence to suggest that some combinations of cannabinoids can cause more negative consequences in PTSD sufferers than the average citizen and that veterans are suffering more from cannabis use disorder than ever before. While high doses of THC might make a PTSD sufferer more prone to anxiety or addiction, higher proportions of CBD and combinations of those other cannabinoids, have been shown to actually improve some neurological functions.

At the end of the day, the crucial question for policy makers, medical professionals with the discretion to allow citizens to become medical marijuana patients, and the patients themselves, is about the risks and rewards of cannabis. While the positive evidence for cannabis is based upon individual anecdotes and experiences, there are mountains of that evidence as high as the Rockies–evidence that comes from decades of therapeutic relief experienced by those from California pioneers like Jack Herer and Dennis Peron 40 years ago to active Veteran advocates like Cloutier and Judge of NEVA who are helping lead the charge in the northeast.

On balancing the risks and rewards, for many it comes down to two fundamental statistics:

22 – The number of American veterans who commit suicide, each day.

0 – The number of overdose deaths from cannabis, ever.

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