Clearing the Haze: Medical Marijuana Policy and PTSD
October 6, 2014
Every week I receive a Google Alert email that lists recent news stories mentioning “posttraumatic stress disorder (PTSD)." The email help keep me abreast of new research, policy developments and discourse about the disorder in the popular press. Recently, the topic of medical marijuana policy has been prominent in the headlines. I did some research to better understand the policy terrain around medical marijuana and PTSD in the United States and elsewhere in the world.
State medical marijuana laws are enacted though a legislative policy process in which a bill is introduced by a Congressperson and then voted on by elected members of congress, or voted on by citizens in the cases of referendums and propositions. Determinations regarding the medical conditions that qualify for permissible medical marijuana use, however, are sometimes (depending on the state) made through administrative policy by state health department officials.
In 2009, New Mexico was the first state to add PTSD to the list of medical conditions for which marijuana use was permitted. According to a report published by Americans for Safe Access in July 2014, the use of medical marijuana for PTSD is legal in eleven additional states: Oregon, Maine, Michigan, Nevada, Connecticut, Delaware, California, Kentucky, Massachusetts, Maryland and Arizona. The processes through which medical marijuana can be obtained, and regulations regarding potency, however, vary dramatically.
In Kentucky, for example, medical marijuana products containing cannabidiol (an active chemical compound in cannabis) are permitted for any medical condition, but products containing tetrahydrocannabinol (THC—the principal, and arguably most therapeutic, compound) are prohibited. Maryland requires physicians to register with the state for each condition they intend to recommend marijuana for, while states such as California and Massachusetts allow individual physicians to use their discretion in determining when medical marijuana might be helpful for their patients. In New Mexico, the regulations to obtain medical marijuana for PTSD are so restrictive that they prompted a neuropsychiatrist to file a law suit against the state’s Department of Health.
Although the number of states permitting medical marijuana for PTSD is proliferating, marijuana is still a considered a Schedule I controlled substance according to federal law, and is thus illegal. Schedule I controlled substances are classified as such by the Controlled Substances Act, signed into law by President Nixon in 1970, and are defined as those with “a high potential for abuse" and "no currently accepted medical use in treatment in the United States” (Sec. 202). Cocaine is classified as a Schedule II controlled substance because it was considered to have lower potential for addiction than marijuana and other Schedule I substances. There have been numerous efforts to amend the Controlled Substances Act to reflect research that has emerged over the past 40 years, but these efforts have been unsuccessful.
One area where federal law and state medical marijuana policy conflicts is in the context of care for patients in the Veterans Health Administration (VHA). On January 31, 2011 the VHA issued Directive 2011-004, entitled “Access to Clinical Programs of Veterans Participating in State Medical Marijuana Programs.” Citing that “Department of Veterans Affairs (VA) providers must comply with all Federal laws, including the Controlled Substances Act,” the directive formally established VA policy “to prohibit VA providers from completing forms seeking recommendations or opinions regarding a Veteran’s participation in a State marijuana program.” In other words, a VHA psychiatrist providing PTSD treatment for a patient in state where medical marijuana has been approved for PTSD cannot discuss medical marijuana with the patient, let a alone write a prescription. In April 2014 Congressman Earl Blumenauer of Oregon introduced federal legislation to nullify Directive 2011-004, but the legislation did not pass.
Outside of the US, marijuana is classified as a Schedule IV drug under the United Nations Single Convention on Narcotic Drugs. This designation allows UN member countries to determine if, and under what circumstances, marijuana is permitted for medical and/or recreational purposes. The legality of medical marijuana and cannabis derivatives varies greatly between countries. With the exceptions of the Netherlands, and perhaps Israel, medical marijuana policy is more liberal in many US states than in other counties.
Medical marijuana has been legal in the Netherlands since 2003 and physicians have discretion to determine when marijuana might benefit their patients. Thus, physicians in the Netherlands are permitted to prescribe marijuana for PTSD. A medical marijuana movement also is afoot in Israel. Select physicians are allowed to prescribe medical marijuana if they declare that attempts to treat a condition using “approved” drugs has proven unsuccessful. Israel’s medical marijuana program currently distributes the drug to approximately 12,000 patients and the number of physicians permitted to prescribe medical marijuana has recently doubled. Even in countries with “zero tolerance” laws regarding substances, such as Croatia, courts have ruled in favor of veterans using marijuana to deal with PTSD. The Croatian high court recently overturned the conviction of a veteran who was convicted of growing marijuana for his own use, concluding that "the defendant suffers from PTSD, and marijuana relaxes him and helps him to overcome psychological problems."
What does the future hold? As reported in the New England Journal of Medicine in August 2014, 21 states and the District of Columbia have passed laws medical marijuana laws—approximately 145.1 million people in the U.S., about 45% of the population—now live in a state where medical marijuana is legal. Are these policy developments a good thing for survivors of trauma? From a research perspective, the empirical evidence is insufficient to say. With the exception of a recent retrospective study of patients who applied to the New Mexico Medical Cannabis Program, and found that the patients experienced a 75% reduction in PTSD symptoms, the impacts of medical marijuana polices for individuals with PTSD symptoms have not been studied. A new study is on the horizon, however, once the many bureaucratic hurdles are surmounted, in which researchers at the University of Arizona College of Medicine hope to perform a triple-blind and placebo-controlled trial of marijuana with combat veterans who served in Iraq and Afghanistan and whose PTSD symptoms have not improved with currently accepted treatments.
Let me know your thoughts about medical marijuana policies and PTSD via this anonymous, single question, open-ended online survey. I’ll share the community’s responses in the next edition of Traumatic StressPoints.
About the Author
Jonathan Purtle, DrPH, MPH, MSc, is assistant professor in the Department of Health Management & Policy at the Drexel University School of Public Health. His research is focused on traumatic stress in urban areas, integrating knowledge about trauma into public health practice, and mixed methods approaches to understanding the social and political contexts through which research translates into policy. He is past recipient of the ISTSS Outstanding Student Advocacy Award for his work writing for The Philadelphia Inquirer about trauma and toxic stress.