Cannabis Patient Care - December 2022

Cannabis Patient Care- December 2022

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10 doctor focus cannabis patient care | vol. 3 no. 4 cannapatientcare.com can be. We frequently encounter situations that trigger anxi- ety or intrusive thoughts; how we respond to these challeng- es determines whether the experience is healing or harmful. After talking to thousands of cannabis users in my clinic, I'm certain that cannabis can be intentionally used to increase the likelihood of healing. For example, I've worked with a 34-year-old veteran who was injured by a roadside explosion in the Middle East. He re- turned to civilian life with recurrent episodes of extreme dis- tress, most commonly triggered by visual stimuli while driv- ing, such as a red flag tied to the end of lumber extending from the back of a pickup truck. These episodes were debilitating until he started using cannabis. He explained that every time he was triggered in this way, he would pull over, take an inha- lation or two of THC-rich cannabis from a pipe he kept in his car, and then meditate for 15–30 min before continuing on his way (assuring me he avoided driving until any potential impair- ment had subsided). One day he was proud to report that see- ing a red flag on the way to the office visit, for the first time since his injury, elicited no adverse response. Perhaps his use of cannabis with every trigger enhanced "fear extinction learn- ing"—he was able to learn that the visual stimulus was actual- ly non-threatening. Clinical Evidence Surprisingly little high-quality research has directly evaluat- ed the effects of medical cannabis on symptoms in patients with anxiety and trauma-related disorders, though the evi- dence is growing. More studies have evaluated the use of nabilone, a synthet- ic THC analogue with better absorption, in patients with anxi- ety and PTSD than we've seen with herbal cannabis. For example, a placebo-controlled crossover trial of na- bilone (0.5–3 mg at bedtime) in 10 military personnel with PTSD demonstrated a significant reduction in nightmares, im- provement in general well-being, and improvement in Clinical Global Impression of Change scores (14). Another double-blind trial of 20 patients with anxiety treat- ed with nabilone (1 mg three times daily) demonstrated dra- matic improvement in anxiety in the nabilone group when compared with placebo (15). In an observational study of six patients requiring multiple antidepressants for mixed anxiety and mood disorders, na- bilone titrated from just 0.25 mg to 1 mg at bedtime showed an average improvement in Generalized Anxiety Disorder scores of 26.5% over 6 months (16). This supports my observa- tion that some patients with anxiety are able to use cannabis in the evening with residual improvements in symptoms the following day, and that the response to this dosing strategy continues to improve over months. In a larger retrospective study of 104 incarcerated men with serious mental illness, treatment with nabilone (average of 4 mg daily) led to significant improvement in PTSD-associ- ated insomnia, nightmares, PTSD symptoms, and Global As- sessment of Functioning scores, as well as improvements in chronic pain. Many of their other medications were able to be discontinued, and there was no evidence of nabilone abuse or diversion. The authors found it particularly noteworthy that, in virtually all subjects, nabilone targeted several symptoms simultaneously (average 3.5 symptoms per participant) (17), an outcome we're used to seeing with cannabis treatments. Other small studies have evaluated synthetic THC. For ex- ample, an open-label pilot study carried out in 10 patients with chronic PTSD, on stable medication, found that adding on 5 mg of THC twice a day led to statistically significant im- provements in global symptom severity, sleep quality, fre- quency of nightmares, and PTSD hyperarousal symptoms (18). There's also some evidence from controlled studies us- ing high-dose, purified CBD. For example, in one placebo-con- trolled study of 24 treatment-naïve patients with generalized social anxiety disorder, pretreatment with 600 mg of CBD be- fore a simulated public speaking test significantly reduced anxiety, cognitive impairment, and discomfort in speech per- formance (19). Not all clinical evidence supporting cannabis for anxiety and trauma-related disorders comes from studies using iso- lated compounds. Eight cross-sectional studies evaluating the use of cannabis or cannabis-derived products reported relief of anxiety as a primary or secondary benefit (20). A retrospec- tive study analyzing PTSD symptoms collected during 80 psy- chiatric evaluations of patients applying to the New Mexico Medical Cannabis Program during 2009–2011 identified >75% reduction in Clinician-Administered PTSD Scale for DSM-IV symptom scores when patients with PTSD were using cannabis compared to when they were not (21). Dr. Sue Sisley and colleague's long-awaited cannabis for military veterans with PTSD clinical trial was finally published in 2021. The trial compared four types of cannabis cigarettes: THC-dominant (type I), mixed THC/CBD (type II), CBD-dominant (type III), and placebo cannabis. Interestingly, all treatment groups (including placebo) achieved statistically significant reductions in PTSD severity. The improvements measured at 3 weeks were much greater than those reported in other drug trials for PTSD at 10 weeks (22). Due to the excellent response in the placebo group, the headlines surrounding this publica- tion indicated the cannabis treatment was ineffective. Though the results in the placebo group are thought-provoking, this study did confirm the benefits reported by so many veterans who smoke cannabis for this purpose. Regarding CBD-dominant cannabis treatment, a large case series found that CBD at doses of 25–175 mg/day reduced anxiety scores in 57 of 72 patients (23). Another case series on 11 adult patients with PTSD found an average of around 50 mg of CBD, added to their routine psychiatric care,

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