Staff Perspective: My client says marijuana helps with PTSD symptoms. That can’t be the case… right?

Staff Perspective: My client says marijuana helps with PTSD symptoms. That can’t be the case… right?

Josh Gray, Ph.D.

For a background of the neurobiological effects of marijuana and an additional perspective see previous posts from Laura Copland, MA, LCMHC.

If a client proclaimed during a session that drugs with abuse potential are beneficial in managing PTSD symptoms, most therapists would identify this as cause for concern. When drugs with abuse potential are used in response to PTSD symptoms, they generally maintain or exacerbate the condition. For example, the classic client with alcohol use disorder and PTSD drinks to avoid trauma-related thoughts and reduce heightened arousal symptoms (e.g., hypervigilance). This impedes the healing process by encouraging avoidance of painful memories, reducing treatment engagement, increasing physiological and psychological dependence on alcohol, and causing added social, occupational, and health consequences. Recreational drugs used to cope with PTSD make things worse, not better. Even benzodiazepines seem to promote avoidance and dependence risk, and are thus now deemed “contraindicated” for PTSD1.

However, given the legalization of medical and/or recreational marijuana in several states and the burgeoning research into its potential as a medicine, members of our field are left to wonder if the same standard applies. In fact, a quick search of recent scientific articles with the terms “marijuana” and “PTSD” brings up seemingly contradicting titles in the top hits:

“Cannabis use disorder treatment barriers and facilitators among veterans with PTSD”2

“Marijuana and other cannabinoids as a treatment for post-traumatic stress disorder: a literature review”3

How can marijuana use be disordered and increase barriers to treatment, but also be palliative or even treat PTSD? A closer look at the latter article reveals a few main points:

  1. Marijuana, particularly heavy and frequent use, is linked with numerous psychiatric conditions including anxiety, depression, psychosis, and substance abuse.
  2. Marijuana is generally associated with avoidant coping (similar to the alcohol example above) and worse treatment outcome.
  3. Research into potential benefits is more limited. Although there were several individual studies where positive effects on insomnia and/or nightmares were identified, the methodology was typically not rigorous, the sample sizes were relatively small, and/or synthetic THC products, rather than whole plant marijuana were used. Noting the limitations is not intended to dismiss these studies as a whole, but to highlight the need for rigorous randomized controlled trials testing an array of potencies and relative concentrations of THC vs. cannabidiol content*.

As it currently stands, there is research indicating potential for harm. Evidence of possible benefits of marijuana use to treat insomnia or nightmares is inconclusive. Further, among veterans with PTSD, 29% have a cannabis use disorder4, suggesting use regularly becomes problematic in this population.

A few parting thoughts on what to keep in mind when working with clients:

  1. It is always important to carefully explore the history, severity, antecedents, and consequences of a client’s use. It will be important to draw a client’s attention to the short term effects of their use in temporarily relieving some discomfort, at the cost of prolonging their symptomatology.
  2. Recall that while research reports marijuana use can add risks across a number of domains and often becomes disordered in individuals with PTSD, other studies have found neutral effects or possible short term benefits on nightmares and sleep. In a client resistant to change and/or with use that appears minimal and non-pathological (e.g., has no history of drug abuse and uses once per week to help sleep versus using daily including before every session), it may be counterproductive to use precious therapy time combating with the client. Continue to monitor the behavior and prioritize the primary presenting problem.
  3. Even in the case of use that is clearly problematic, it is important to use a motivational interviewing5 approach to explore the client’s values and reasons for and against use, and only offer expert advice after permission from the client. As motivational interviewing teaches us, a dismissive critique of the client’s use will only prompt them to dig their heels in further.

*Note that this blog post pertains to use of whole marijuana plant. Marijuana is comprised of two primary active compounds, THC and cannabidiol. THC contains the psychoactive properties that get one high and is responsible for the aforementioned risks. The latter, cannabidiol, has numerous putative benefits under study, including reducing psychosis6, and has minimal risk when administered in isolation.

Joshua C. Gray, Ph.D., is a clinical psychologist with the Center for Deployment Psychology at the Uniformed Services University (USU) in Bethesda, Maryland. He recently completed his clinical internship at Brown University/Providence VA, where he received training in treating primarily addiction and PTSD. He is a published researcher with a focus on the neurobiology of impulsivity and addiction. He plans to join USU as an assistant professor in the fall of 2017. Follow him on Twitter at @JoshChGray

1Guina, J., Rossetter, S. R., DeRhodes, B. J., Nahhas, R. W., & Welton, R. S. (2015). Benzodiazepines for PTSD: a systematic review and meta-analysis. Journal of Psychiatric Practice, 21(4), 281-303.

2Bujarski, S. J., Galang, J. N., Short, N. A., Trafton, J. A., Gifford, E. V., Kimerling, R., ... & Bonn-Miller, M. O. (2016). Cannabis use disorder treatment barriers and facilitators among veterans with PTSD. Psychology of Addictive Behaviors, 30(1), 73-81.

3Steenkamp, M. M., Blessing, E. M., Galatzer‐Levy, I. R., Hollahan, L. C., & Anderson, W. T. (2017). Marijuana and other cannabinoids as a treatment for posttraumatic stress disorder: A literature review. Depression and Anxiety. 34, 207-216.

4Bonn-Miller, M. O., Harris, A. H., & Trafton, J. A. (2012). Prevalence of cannabis use disorder diagnoses among veterans in 2002, 2008, and 2009. Psychological Services, 9(4), 404-416.

5Miller, W. R., & Rollnick, S. (2012). Motivational interviewing: Helping people change. 3rd edition. The Guilford Press.

6Rohleder, C., Müller, J. K., Lange, B., & Leweke, F. M. (2016). Cannabidiol as a potential new type of an antipsychotic. A critical review of the evidence. Frontiers in Pharmacology, 7, 422.