|
Spring 2006
O'Shaughnessy's
Journal of the California Cannabis Research Medical
Group |
Patients Out-of Time
Perspectives
PTSD and Cannabis: A Clinician
Ponders Mechanism of Action
By David Bearman, MD
One often intractable problem for which cannabis provides
relief is post-traumatic stress disorder (PTSD). I have more than 100
patients with PTSD.
Among those reporting that cannabis alleviates
their PTSD symptoms are veterans of the war in Vietnam, the first Gulf
War, and the current occupation of Iraq. Similar benefit is reported by
victims of family violence, rape and other traumatic events, and
children raised in dysfunctional families.
Post-Traumatic
Stress Disorder
Post-Traumatic Stress Disorder —once
referred to as “shell shock” or “battle fatigue” — is a debilitating
condition that follows exposure to ongoing emotional trauma or in some
instances a single terrifying event. Many of those exposed to such
experiences suffer from PTSD. The symptoms of PTSD include persistent
frightening thoughts with memories of the ordeal. PTSD patients have
frightening nightmares and often feel anger and an emotional
isolation.
Sadly, PTSD is a common problem. Each year millions of
people around the world are affected by serious emotional trauma. In
more than 100 countries there is recurring violence based on ethnicity,
culture, religion or political orientation.
Men, women and children
suffer from hidden sexual and physical abuse. The trauma of molestation
can cause PTSD. So can rape, kidnapping, serious accidents such as car
or train wrecks, natural disasters such as floods or earthquakes,
violent attacks such as mugging, torture, or being held captive.
The
event that triggers PTSD may be something that threatened the person’s
life or jeopardized someone close to him or her. Or it could simply be
witnessing acts of violence, such as a mass destruction or massacre.
PTSD can affect survivors, witnesses and relief
workers.
Symptoms
Whatever the source of the
problem, PTSD patients continually relive the traumatic experience in
the form of nightmares and disturbing recollections. They are
hyper-alert. They may experience sleep problems, depression, feelings of
emotional detachment or numbness, and may be be easily aroused or
startled. They may lose interest in things they used to enjoy and have
trouble feeling affectionate. They may feel irritable, be violent, or be
more aggressive than before the traumatic exposure.
Triggers
Seeing things that remind them of the
incident(s) may be very distressing, which could lead them to avoid
certain places or situations that bring back those memories.
Anniversaries of a traumatic event are often difficult.
Ordinary
events can serve as reminders of the trauma and trigger flashbacks or
intrusive images. Movies about war or TV footage of the Iraqi war can be
triggers. People with PTSD may respond disproportionately to more or
less normal stimuli —a car backfiring, a person walking behind them. A
flashback may make the person lose touch with reality and re-enact the
event for a period of seconds, hours or, very rarely, days. A person
having a flashback in the form of images, sounds, smells, or feelings
experiences the emotions of the traumatic event. They relive it, in a
sense.
Symptoms may be mild or severe — people may become easily
irritated or have violent outbursts. In severe cases victims may have
trouble working or socializing. Symptoms can include:
• Problems in
affect regulation —for instance persistent depressive symptoms,
explosion of suppressed anger and aggression alternating with blockade
and loss of sexual potency;
• Disturbance of conscious experience,
such as amnesia, dissociation of experience, emotions, and
feelings;
• Depersonalization (feeling strange about oneself),
rumination;
• Distorted self-perception —for instance, feeling of
helplessness, shame, guilt, blaming oneself, self-punishment,
stigmatization, and loneliness;
• Alterations in perception of the
perpetrator —for instance, adopting distorted beliefs, paradoxical
thankfulness, idealization of perpetrator and adoption of his system of
values and beliefs;
• Distorted relationship to others, for instance,
isolation, retreat, inability to trust, destruction of relations with
family members, inability to protect oneself against becoming a victim
again;
• Alterations in systems of meaning, for instance, loss of
hope, trust and previously sustaining beliefs, feelings of
hopelessness;
• Despair, suicidal thoughts and preoccupation;
•
Somatization —for instance persistent problems in the digestive system,
chronic pain, cardiopulmonary symptoms (shortness of breath, chest pain,
dizziness, palpitations).
• Cannabis
Ample
anecdotal evidence suggests that cannabis enhances ability to cope with
PTSD. Many combat veterans suffering from PTSD rely on cannabis to
control their anger, nightmares and even violent rage. Recent research
sheds light on how cannabis may work in this regard.
Neuronal and
molecular mechanisms underlying fearful memories are often studied in
animals by using “fear conditioning.” A neutral or conditioned stimulus,
which is typically a tone or a light, is paired with an aversive
(unconditioned) stimulus, typically a small electric shock to the foot.
After the two stimuli are paired a few times, the conditioned stimulus
alone evokes the stereotypical features of the fearful response to the
unconditioned stimulus, including changes in heart rate and blood
pressure and freezing of ongoing movements. Repeated presentation of the
conditioned stimulus alone leads to extinction of the fearful response
as the animal learns that it need no longer fear a shock from the tone
or light.
• Fear Extinction
Emotions and memory
formation are regulated by the limbic system, which includes the
hypothalamus, the hippocampus, the amygdala, and several other
structures in the brain that are particularly rich in CB1 receptors.
The amygdala, a small, almond-shaped region lying below the
cerebrum, is crucial in acquiring and, possibly, storing the memory of
conditioned fear. It is thought that at the cellular and molecular
level, learned behavior —including fear— involves neurons in the
baso-lateral part of the amygdala, and changes in the strength of their
connection with other neurons (“synaptic plasticity”).
CB1 receptors
are among the most abundant neuroreceptors in the central nervous
system. They are found in high levels in the cerebellum and basal
ganglia, as well as the limbic system. The classical behavioral effects
of exogenous cannabinoids such as sedation and memory changes have been
correlated with the presence of CB1 receptors in the limbic system and
striatum.
In 2003 Giovanni Marsicano of the Max Planck Institute of
Psychiatry in Munich and his co-workers showed that mice lacking normal
CB1 readily learn to fear the shock-related sound, but in contrast to
animals with intact CB1, they fail to lose their fear of the sound when
it stops being coupled with the shock.
The results indicate that
endocan-nabinoids are important in extinguishing the bad feelings and
pain triggered by reminders of past experiences. The discoveries raise
the possibility that abnormally low levels of cannabinoid receptors or
the faulty release of endogenous cannabinoids are involved in
post-traumatic stress syndrome, phobias, and certain forms of chronic
pain.
This suggestion is supported by our observation that many
people smoke marijuana to decrease their anxiety and many veterans use
marijuana to decrease their PTSD symptoms. It is also conceivable,
though far from proved, that chemical mimics of these natural substances
could allow us to put the past behind us when signals that we have
learned to associate with certain dangers no longer have meaning in the
real world.
What is the Mechanism of Action?
Many
medical marijuana users are aware of a signaling system within the body
that their doctors learned nothing about in medical school: the
endocan-nabinoid system. As Nicoll and Alger wrote in “The Brain’s Own
Marijuana” (Scientific American, December 2004):
“ Researchers have
exposed an entirely new signaling system in the brain: a way that nerve
cells communicate that no one anticipated even 15 years ago. Fully
understanding this signaling system could have far-reaching
implications. The details appear to hold a key to devising treatments
for anxiety, pain, nausea, obesity, brain injury and many other medical
problems.”
As a clinician, I find the concept of retrograde signaling
extremely useful. It helps me explain to myself and my patients why so
many people with PTSD get relief from cannabis.
We are taught in
medical school that 70% of the brain is there to turn off the other 30%.
Basically our brain is designed to modulate and limit both internal and
external sensory input.
The neurotransmitter dopamine is one of the
brain’s off switches.The endocannabinoid system is known to play a role
in increasing the availability of dopamine. I hypothesize that it does
this by freeing up dopamine that has been bound to a transporter, thus
leaving dopamine free to act by retrograde inhibition.
By release of
dopamine from dopamine transporter, cannabis can decrease the sensory
input stimulation to the limbic system and it can decrease the impact of
over-stimulation of the amygdala.
I postulate that exposure to the
PTSD-inducing trauma causes an increase in production of dopamine
transporter. The dopamine transporter ties up much of the free dopamine.
With the brain having lower-than-normal free dopamine levels, there are
too many neural channels open, the mid-brain is overwhelmed with stimuli
and so too is the cerebral cortex. Hard-pressed to react to this stimuli
overload in a rational manner, a person responds with anger, rage,
sadness and/or fear.
With the use of cannabis or an increase in the
natural cannabinoids (anandamide and 2-AG), there is competition with
dopamine for binding with the dopamine transporter and the cannabinoids
win, making a more normal level of free dopamine available to act as a
retrograde inhibitor.
This leads to increased inhibition of neural
input and decreased negative stimuli to the midbrain and the cerebral
cortex. Since the cerebral cortex is no longer overrun with stimuli from
the midbrain, the cerebral cortex can assign a more rational meaning and
context to the fearful memories.
I have numerous patients with PTSD
who say “marijuana saved my life,” or “marijuana allows me to interact
with people,” or “it controls my anger,” or “when I smoke cannabis I
almost never have nightmares.” Some say that without marijuana they
would kill or maim themselves or others. I have no doubt that cannabis
is a uniquely useful treatment. What remains is for the chemists to
determine the precise mechanism of action.
Oregon in Denial Over Cannabis as
an Antidepressant
By Ed Glick
I’ve been working as a
nurse for 25 years, about half of that in acute care mental health
nursing at Good Samaritan Regional Medical Center in Corvallis, Oregon.
Eight years ago the Oregon Medical Marijuana Act pass-ed by the
initiative process and a state program began registering patients.
It
wasn’t long before I started meeting patients coming into the regional
mental health unit who reported that they were using cannabis to
self-medicate for a variety of mental-health symptoms. It wasn’t long
after that that I started volunteering at the Compassion Center, a
volunteer medical facility that helps assist patients with education,
support and registration into the medical marijuana program.
Pretty
soon I started seeing the same patients who were having psychiatric
emergencies coming to the Compassion Center to see me for cannabis
recommendations, which I can’t provide and which, actually, they
couldn’t get because there is no allowance in Oregon for psychiatric
treatments. All the “debilitating conditions” are physical with the
exception of Alzheimer’s agitation.
In Corvallis, a very progressive
community, there is virtually no doctor who will recommend cannabis for
cancer pain or for severe nausea or AIDS. The whole medical system of
Corvallis said “No, you’re locked out.” So then I go down to the
Compassion Center and all these people from the medical system that I’m
employed in say, “My doctor won’t do it, he’s afraid he’ll lose his
license.”
So we assist these people by trying to find a physical
correlation to their psychiatric symptom. For example, if they’re having
PTSD symptoms they might be sick and have physical symptoms.
How
high a percentage of these people were treating psychiatric symptoms? I
put together a very simple survey to find out. I reviewed 172 charts.
The average patient age was 43. All the patients were registered in
OMMA; 95% were registered for pain. A very large percentage of Oregon
registrants are pain patients.
Some 40% had multiple qualifying
conditions (not including psychiatric) —physical pain and nausea, for
example. Pain and with spasticity —they often go together.
The
results: 64% of the patients in the survey showed some kind of
significant psychiatric benefit; 39% reported insomnia relief; 5%
reported PTSD symptom relief, many of them veterans who go to the VA
hospital in Roseburg and are denied. The VA doctors tell them “No, I
can’t. I’ll lose my DEA license.” They just don’t want to stand up to it
—although they’re beginning to refer patients to us, which is kind of
interesting.
Anxiety, 11%; depressive symptoms, 11%; 15% of the
cohort reported that they were using cannabis to decrease the side
effects of medications; 56% reported reduced use of medications.
What
these patients report to me is that they’re sick and tired of Vioxx and
they’re sick and tired of Flexeril, Vicodin —people are literally sick
of these drugs. They can’t sleep, they can’t function, they’re drugged
up, they don’t have any enjoyment of life.
When they start using
cannabis they leave off the Vioxx and they leave off the Vicodin.
Vicodin has a place, but for long-term pain management it is really
poor.
Appetite stimulation —tremendously important for people who are
in pain all the time— was 20%.
I put the survey together as a request
to the Oregon Department of Human Services to reconvene the Debilitating
Conditions Advisory Panel, which I was a member of in 2000. At that time
nine patients had submitted requests to include psychiatric conditions
to the list.
The state health officer did a fairly good job of
bringing together the panel, but the whole thing was skewed from the
outset by political manipulation by the governor’s office and by the
head of the Department of Health Services. The information that they
would allow us to consider had to be filtered through rules stating that
if it’s not a double-blind, peer-reviewed clinical trial, it doesn’t get
a lot of evidentiary weight.
We were not allowed to give much weight
to patients’ reports. And of course there was no relevant double-blind,
peer-reviewed clinical trial. So the panel was set up to fail.
A few
patients came in and gave very compelling testimonials. And then out of
nowhere came a whole bunch of medical experts —psychiatrists from Oregon
Health Sciences University and the National Alliance for the Mentally
Ill— and they just had fits. “This is quackery,” they said.
The only
person who even differentiated between affective depressive-type
disorders and schizophrenic thought disorders was one of the patients.
None of the doctors even made any differentiation between these two
completely different sets of medical problems.
After a long,
protacted time we all wrote our comments out, and there was a vote, and
we voted to add affective disorders —severe agitation and depressive
symptoms. Didn’t happen. They finally did add Alzheimer’s agitation.
So, five years later I brought in the study I’d done with OMMP
registrants and asked them to reconvene the Debilitating Conditions
Panel based on this new evidence showing that indeed there is some
psychiatric effect that people are getting from their cannabis use. And
they rejected the request with a “summary denial.”
Then Lee Berger,
an attorney in Portland, asked if I’d be willing to sue the Department
of Human Services’ OMMP and I said yes. We filed our petition for
judicial review in February —a formal request “to Add Clinical
Depression, Depressive Symptoms, Post-Traumatic Stress Disorder (PTSD),
Severe Anxiety, Agitation and Insomnia, to Those Diseases and Conditions
Which Qualify as ‘Debilitating Medical Conditions’ under the Oregon
Medical Marijuana Act.” And it worked! I can’t believe it!
We got
word last week that, because the OMMP doesn’t really want to go to
court, they’ve decided to kind of sue for peace. All we’re asking is
that they reconvene a panel to evaluate these conditions. So, we’re in
the process of negotiatng with them to get this thing back on
track.
We want to close some of the loopholes that allow them to skew
the evidence base. It’s pretty clear that there are a lot of patients
who are using cannabis for insomnia, for mood stabilizing, and for
peace. Just for a a very simple, elemental peace, especially with
chronic diseases like severe chronic pain. Cannabis is actually a
miracle drug for pain, in my opinion.
There’s no question the last
thing the pharmacy industry wants is millions and millions of Americans
growing and using their own medicine that covers such a wide array of
diseases.
Rodney Dangerfield's Lifelong
Romance With Marijuana
By Joan Dangerfield
The comedian’s
widow gave this talk at the Patients Out of Time conference on cannabis
therapeutics in Santa Barbara April 7.
If Rodney were here
today he would say something brilliant. He would probably open with a
marijuana joke. He’d say, “I tell ya, that marijuana really has an
effect on you. The other day I smoked a half a joint and I got so
hungry, I ate the other half.”
Rodney had a fantastically unique
mind. Few people knew he was a mathematical genius, but everyone knew he
was hilarious. His humor was a razor thrust into social hypocrisy and
the little injustices of life. He wrote “killers” and made the world
laugh.
Another thing that was not widely known about Rodney is that
he endured quite a bit of personal suffering in his life. He was
heartbreakingly neglected as a child. We’ve all heard the expression
“the tears of a clown,” and in many ways Rodney embodied that
experience. Like most geniuses, the special chemistry that created his
remarkable mind also created certain psychological challenges. Acute
anxiety and manic depression were congenital issues that plagued
Rodney’s life.
To give you an idea of how his anxiety would manifest
itself, Rodney couldn’t sit still. In Caddyshack, his character, Al
Cervic, is constantly fidgeting like he’s about to burst out of his
skin. The truth is, this was no act. Rodney was under duress. He felt
Chevy Chase was talking too slowly and it got on his nerves. Rodney’s
impatience would come out through his body. The pace of the whole world
was too slow for him until he found marijuana.
Rodney first lit up
back in 1942 when he was 21. He was hanging out with a comic named Bobby
Byron and his friend Joe E. Ross —some of you might remember Joe E. Ross
from Car 54. They went to the Belvedere Hotel in New York where Bobby
lived. The night would prove to have such an impact on Rodney’s life
that he even remembered the room number they were in —1411.
Although
he was supposed to be enjoying himself with friends, Rodney was
characteristically agitated and anxiety ridden. It’s how he felt every
day of his life to that point. But when Rodney got high, he couldn’t
believe it.
For the first time in his life, he left relaxed and
peaceful, and had a sense of well-being. That night marijuana became a
new friend that would be in Rodney’s life for the next 62 years.
I
met Rodney in 1983, and after a 10-year courtship, Rodney and I enjoyed
11 years of marriage. I must admit that when I became a part of Rodney’s
life, I did not approve of his marijuana use. My Mormon background
hadn’t given me experience with any illegal substances and I was always
afraid Rodney would get arrested.
Rodney was concerned about my
feelings and agreed to look for legal alternatives to treat his
ailments. Over the years we consulted the best experts we could find in
search of legal anti-anxiety and pain medications and even tried
Marinol. But nothing worked for him the way real marijuana did.
A
couple of years ago Rodney was in the process of writing his
autobiography, in which he wanted to be very candid about everything in
his life. He even wanted to title the book “My Lifelong Romance with
Marijuana.”
I was sure then that Rodney would be arrested. So I
looked for, and found, Dr. David Bearman here in Santa Barbara.
Dr.
Bearman examined Rodney and obtained records from Rodney’s other doctors
for review. In addition to his anxiety and depression, at the time
Rodney’s medical conditions included constant pain from the congenital
fusion of his spine, an inoperable dislocated shoulder and rotator-cuff
tear and arthritis. Rodney wasn’t able to take traditional pain
medications because of their interactions with his blood-thinning
medication, Coumadin.
We were elated a few days after that initial visit with Dr. Bearman
when Rodney’s medicinal use was approved. Rodney showed the approval
letter to everyone and carried miniature versions in his pockets. Ever
the worried wife, I included a copy of the letter in the memory box of
his casket in case the feds were waiting for him at the Pearly
Gates.
Even though Rodney endured numerous health challenges over the
years, including aneurysms, heart surgeries and a brain bypass, he
remained active and vital during his last incredible year. He swam
regularly, went on a multi-city press tour to promote his best-selling
book (the publisher made him change the title to “It’s Not Easy Bein’
Me”), recorded an album of love songs called “Romeo Rodney,” and wrote
countless new jokes.
After all those years of pot smoking, his memory
and his joke-writing ability did not suffer and his lungs were okay. He
was as sharp as ever.
Even moments after brain surgery Rodney didn’t
miss a beat. Rodney’s doctor came to his bedside after he was taken off
the respirator. He said, “Rodney, are you coughing up much?” And Rodney
said, “Last week, five-hundred for a hooker.”
Some of you may be
aware that 4:20 is a symbolic time of day for many marijuana
enthusiasts. About a year after Rodney’s brain surgery, he had heart
surgery and due to complications his life ended... Coincidentally, or
perhaps meaningfully, at 4:20 p.m. EST.