Short and Long-Term Effects of Cannabis on Symptoms of Post-Traumatic Stress Disorder

Effects of medical cannabis use on physical and psychiatric symptoms across the day among older adults

INTRODUCTION

Older adults are increasingly using medical cannabis (MC). It is unclear if therapeutic effects increase problematic use patterns. The current study addresses this issue by examining symptom trajectories across the day and using trajectories to predict problematic use.

METHODS

One-hundred six older adults (age range 55-74) who endorsed medical conditions approved for treatment using MC were recruited online. Participants received six text messages/day to assess momentary symptoms for 15 days.

RESULTS

Participants provided 5,156 momentary assessments across 1,106 use days. Symptom trajectories were examined across the day. There was a decline in all symptoms following use. Negative affect, pain, and nausea evinced momentary negative reinforcement associations with cannabis intoxication. Momentary negative reinforcement was associated with adverse cannabis outcomes. Declines in post-use trauma symptoms and momentary negative reinforcement effects for negative affect were both associated with cannabis use disorder symptoms.

DISCUSSION

These data suggest that MC may be effective in reducing common symptom clusters. However, the negative reinforcing effect (i.e., the link between use and symptom relief at the event level) may complicate the therapeutic nature (i.e., symptom reduction). Identifying interventions to maximize benefits while minimizing costs may increase the efficacy and safety of MC in older adults.

Cannabidiol (CBD) Products: Use Patterns and Perceptions Within a Sample of Anxious Users

INTRODUCTION

Cannabidiol (CBD) shows promise for a variety of indications, including anxiety. Prior survey work indicates anxiety ranks as a top reason for which people use cannabidiol (CBD), but no work has evaluated individuals using CBD specifically for anxiety.

METHOD

The current study evaluated CBD product use patterns and perceptions within a sample of 81 participants (Mage = 32.63, SDage = 12.99) who reported using CBD products for anxiety-related concerns within the past 30 days.

RESULTS

Family and friends, followed by popular and scientific literature, were the most common sources informing participants' decision to use CBD products to target anxiety. On average, participants reported using CBD products daily for at least a year and indicated it was very effective in targeting anxiety-related symptoms. The top three ranked symptoms improved by CBD products were subjective anxiety, difficulty falling asleep, and irritability. These findings were despite the fact that the most frequent dosing levels (∼50mg) were well below those empirically observed to yield anxiolytic effects. Most participants denied side effects, adding to the literature supporting CBD products' safety and tolerability. Finally, participants were generally poorly informed about the nature of CBD products (e.g., distinction from THC), suggesting a need for consumer education.

CONCLUSION

Collectively, the current study extends prior survey work suggesting powerful expectancies about CBD products, particularly in terms of anxiety reduction, including among those using it to target anxiety-related symptoms. Findings also highlight the importance of addressing the gap between scientific and consumer knowledge.

Using Smartphone Technology to Track Real-Time Changes in Anxiety/Depression Symptomatology Among Florida Cannabis Users

Objective

Recent scientific attention has focused on the therapeutic effectiveness of cannabis use on a variety of physical and mental ailments. The present study uses smartphone technology to assess self-reported experiences of Florida cannabis users to understand how cannabis may impact anxiety and depression symptomatology.

Method

Several hundred Releaf App™ users from the state of Florida provided anonymous, real-time reports of their symptoms of anxiety and/or depression immediately before and after cannabis use sessions. Linear mixed-effects modeling was used to analyze the data at the symptom and user level.

Results

Results showed that for the majority of users, cannabis use was associated with a significant decrease in depression and anxiety symptomatology. While symptom type, doses per session, consumption method, and CBD levels were significant predictors of relief change, their effect sizes were small and should be interpreted with caution. At the user level, those who had positive relief outcomes in anxiety reported more doses and sessions, and those in the depression group reported more sessions.

Conclusions

Our results generally support the therapeutic effectiveness of cannabis against depression/anxiety symptomatology. Future work should include standardized statistics and effect size estimates for a better understanding of each variable's practical contribution to this area of study.

PTSD, distress and substance use in the aftermath of October 7th, 2023, terror attacks in Southern Israel

The October 7th, 2023, terror attacks in Israel were characterized by a scope and magnitude not previously known to Israeli citizens. The aim of this study was to examine the prevalence and correlates of posttraumatic stress disorder (PTSD), emotional distress and use of addictive substances among Israeli adults, approximately one month following the attacks. PTSD was assessed with the Posttraumatic Stress Disorder Checklist (PCL-5) and emotional distress was assessed with a brief version of the Hopkins Symptom Checklist (HSCL-25). Participants also ranked the degree of change in their frequency of use of six addictive substances. The final sample consisted of 415 Jewish and Arab Israeli adults. Results indicate that one month following the attacks, 31.4% of the total sample qualified for positive screening of PTSD. An increase in the use of tobacco, alcohol, tranquilizers and sleep medications was reported by 16.5%, 10.1%, 11.1% and 10.6% of the sample, respectively. Being at a younger age, of female sex and with increased exposure to the attacks was associated with increased levels of PTSD (β = -0.24, p < 0.001; β = 0.19, p < 0.001 and β = 0.29, p < 0.001, respectively) and increased distress (β = -0.22, p < 0.001, β = 0.26, p < 0.001 and β = 0.19, p < 0.001, respectively). Being male was significantly associated with increased use of cannabis (Adjusted Odds Ratio (AOR) = 4.73, 95% Confidence Interval (CI) = 1.70-13.13, p = 0.003), and level of exposure to traumatic events was significantly associated with increased use of tranquilizers (AOR = 1.58, 95% CI = 1.17-2.13, p = 0.003). The high magnitude of symptomatic response should alert other countries as they prepare for national disasters.

Cannabinoids in the Treatment of Selected Mental Illnesses: Practical Approach and Overview of the Literature

Although an increasing number of patients suffering from mental illnesses self-medicate with cannabis, current knowledge about the efficacy and safety of cannabis-based medicine in psychiatry is still extremely limited. So far, no cannabis-based finished product has been approved for the treatment of a mental illness. There is increasing evidence that cannabinoids may improve symptoms in autism spectrum disorder (ASD), Tourette syndrome (TS), anxiety disorders, and post-traumatic stress disorder (PTSD). According to surveys, patients often use cannabinoids to improve mood, sleep, and symptoms of attention deficit/hyperactivity disorder (ADHD). There is evidence suggesting that tetrahydrocannabinol (THC) and THC-containing cannabis extracts, such as nabiximols, can be used as substitutes in patients with cannabis use disorder.Preliminary evidence also suggests an involvement of the endocannabinoid system (ECS) in the pathophysiology of TS, ADHD, and PTSD. Since the ECS is the most important neuromodulatory system in the brain, it possibly induces beneficial effects of cannabinoids by alterations in other neurotransmitter systems. Finally, the ECS is an important stress management system. Thus, cannabinoids may improve symptoms in patients with mental illnesses by reducing stress.Practically, cannabis-based treatment in patients with psychiatric disorders does not differ from other indications. The starting dose of THC-containing products should be low (1-2.5 mg THC/day), and the dose should be up-titrated slowly (by 1-2.5 mg every 3-5 days). The average daily dose is 10-20 mg THC. In contrast, cannabidiol (CBD) is mainly used in high doses>400 mg/day.

Enhancing massed prolonged exposure with cannabidiol to improve posttraumatic stress disorder: Design and methodology of a pilot randomized clinical trial

Background

The impact of posttraumatic stress disorder (PTSD) is substantial and often results in pervasive functional impairments. Although evidence-based treatments for PTSD are established, there remains room for improvement as many individuals continue to meet diagnostic criteria even after successful treatment completion. Cannabidiol (CBD) has attracted considerable attention based on its potential to treat a myriad of health conditions. CBD may decrease anxiety and facilitate extinction learning processes, two critical targets of trauma-focused psychotherapies. We present the design and methods for a pilot randomized clinical trial to examine the combination of CBD and prolonged exposure for PTSD.

Methods

Participants (n = 24) will be randomized to CBD or placebo for 18 days delivered in combination with ten daily prolonged exposure sessions over two weeks. The study medication will be Epidiolex® (250 mg BID). The PTSD Checklist for DSM-5 will be the primary outcome to assess PTSD severity at baseline, during treatment, and at 1-month follow-up. Blood, saliva, and heart rate will be collected during treatment to assess intervention effects on biological outcomes related to PTSD and the endocannabinoid system.

Results

Consistent with the purpose of a pilot, our goals are to evaluate the feasibility of study procedures, safety of the intervention, and the preliminary effect of CBD to inform a larger trial. Descriptive and inferential statistics will be used to address study aims.

Conclusion

Findings will inform decision making on combining CBD with behavioral interventions for PTSD to enhance outcomes and mitigate the morbidity of this debilitating condition.

Involvement of cannabinoid receptors and neuroinflammation in early sepsis: Implications for posttraumatic stress disorder

Sepsis is associated with several comorbidities in survivors, such as posttraumatic stress disorder (PTSD). This study investigated whether rats that survive sepsis develop the generalization of fear memory as a model of PTSD. Responses to interventions that target the endothelin-1 (ET-1)/cannabinoid system and glial activation in the initial stages of sepsis were evaluated. As a control, we evaluated hyperalgesia before fear conditioning. Sepsis was induced by cecal ligation and puncture (CLP) in Wistar rats. CLP-induced sepsis with one or three punctures resulted in fear generalization in the survivors 13 and 20 days after the CLP procedure, a process that was not associated with hyperalgesia. Septic animals were intracerebroventricularly treated with vehicle, the endothelin receptor A (ETA) antagonist BQ123, the cannabinoid CB1 and CB2 receptor antagonists AM251 and AM630, respectively, and the glial blocker minocycline 4 h after CLP. The blockade of either CB1 or ETA receptors increased the survival rate, but only the former reversed fear memory generalization. The endothelinergic system blockade is important for improving survival but not for fear memory. Treatment with the CB2 receptor antagonist or minocycline also reversed the generalization of fear memory but did not increase the survival rate that was associated with CLP. Minocycline treatment also reduced tumor necrosis factor-α levels in the hippocampus suggesting that neuroinflammation is important for the generalization of fear memory induced by CLP. The influence of CLP on the generalization of fear memory was not related to Arc protein expression, a regulator of synaptic plasticity, in the dorsal hippocampus.

Challenges and considerations for treating PTSD with medicinal cannabis: the Australian clinician's perspective

INTRODUCTION

Preclinical and experimental research have provided promising evidence that medicinal cannabis may be efficacious in the treatment of posttraumatic stress disorder (PTSD). However, implementation of medicinal cannabis into routine clinical therapies may not be straightforward.

AREAS COVERED

In this review, we describe some of the clinical, practical, and safety challenges that must be addressed for cannabis-based treatment of PTSD to be feasible in a real-world setting. These issues are especially prevalent if medicinal cannabis is to be combined with trauma-focused psychotherapy.

EXPERT OPINION

Future consideration of the clinical and practical considerations of cannabis use in PTSD therapy will be essential to both the efficacy and safety of the treatment protocols that are being developed. These issues include dose timing and titration, potential for addiction, product formulation, windows of intervention, and route of administration. In particular, exposure therapy for PTSD involves recall of intense emotions, and the interaction between cannabis use and reliving of trauma memories must be explored in terms of patient safety and impact on therapeutic outcomes.

Cannabinoid Profiles in Medical Cannabis Users: Effects of Age, Gender, Symptoms, and Duration of Use

Introduction: Clinical trials remain the gold standard for evaluating efficacy, but there is increasing interest in using real-world evidence (RWE) to inform health care decision making. The aims of this observational study were to describe patterns of medical cannabis use, associated changes in symptom severity over time, and to evaluate change in cannabis dose over time for pain-related symptoms. Methods: Data were collected by Strainprint^™, an application that is HIPAA, PIPEDA, and PHIPA compliant. A total of 629 participants recorded data between May 2017 and August 2019. A total of 65 symptoms were grouped as Pain, Mental Health, Physical Symptoms, Seizures, Headaches/Migraines, and Other. Descriptive statistics and mixed-effects modeling were applied. Results: THC-dominant products were more frequently consumed for symptoms of pain and sleep, while CBD-dominant products were more frequently consumed for anxiety and depression. Male and female participants demonstrated significant differences in the type of cannabis they consumed. Females more frequently consumed CBD-dominant products, and males more frequently consumed balanced (THC:CBD) products. Oil use was more prominent among females, while vaping was more common among males. Product use also varied by age tertiles (<31; 31-39; >40 years). CBD-dominant products were more common among younger participants, <31 years, THC-dominant products were more common among the 31-39 years category and balanced (THC:CBD) products were common among older participants >41 years. Dosages of CBD-dominant and balanced (THC:CBD) products increased over time irrespective of symptom response. THC-dominant products demonstrated a significant relationship between dose and symptom reduction over time. Conclusions: Recognizing that RWE has important methodological limitations, we observed cannabis product preferences based on demographic characteristics, such as gender and age and the primary symptom treated such as pain and anxiety. Our study offers real-world insights into how participants use and respond to cannabis products and suggests important avenues and methodologies for future research.

Posttraumatic stress disorder, sleep and medical cannabis treatment: A daily diary study

Despite increasing use of Medical Cannabis (MC) among posttraumatic stress disorder (PTSD) patients, research is lacking on how MC treatment relates to PTSD symptomatology, in particular sleep disturbances. This study examines the time gap between MC use and sleep onset and its association with (1) number of awakenings throughout the night, (2) early awakenings, (3) nightmares. Each morning over a two week period, 77 licensed MC patients suffering from PTSD reported on the timing of previous night MC use and sleep disturbances. Within-person analyses found that shorter time gaps between previous night MC use and sleep start time was associated with lower likelihood of experiencing nightmares throughout the night, but it was not associated with nightly awakenings or waking up too early. Between-person analyses showed that individuals who used MC products with higher CBD concentrations reported fewer early awakenings. These preliminary results indicate that future research should test causal relations between MC use and sleep problems in PTSD patients. Future research is warranted in order to explore causal relationships between MC use, nightmares and insomnia in PTSD patients.

Assessment of clinical outcomes in patients with post-traumatic stress disorder: analysis from the UK Medical Cannabis Registry

BACKGROUND

The current paucity of clinical evidence limits the use of cannabis-based medicinal products (CBMPs) in post-traumatic stress disorder (PTSD). This study investigates health-related quality of life (HRQoL) changes and adverse events in patients prescribed CBMPs for PTSD.

METHODS

A case-series of patients from the UK Medical Cannabis Registry was analyzed. HRQoL was assessed at 1-, 3-, and 6-months using validated patient reported outcome measures (PROMs). Adverse events were analyzed according to the Common Terminology Criteria for Adverse Events version 4.0. Statistical significance was defined as p < 0.050.

RESULTS

Of 162 included patients, 88.89% (n = 144) were current/previous cannabis users. Median daily CBMP dosages were 5.00 (IQR: 0.00-70.00) mg of cannabidiol and 145.00 (IQR: 100.00-200.00) mg of Δ9-tetrahydrocannabinol. Significant improvements were observed in PTSD symptoms, sleep, and anxiety across all follow-up periods (p < 0.050). There were 220 (135.8%) adverse events reported by 33 patients (20.37%), with the majority graded mild or moderate in severity (n = 190, 117.28%). Insomnia and fatigue had the greatest incidence (n = 20, 12.35%).

CONCLUSIONS

Associated improvements in HRQoL were observed in patients who initiated CBMP therapy. Adverse events analysis suggests acceptability and safety up to 6 months. This study may inform randomized placebo-controlled trials, required to confirm causality and determine optimal dosing.

Cannabis-Based Medicinal Products in the Management of Emotionally Unstable Personality Disorder (EUPD): A Narrative Review and Case Series

Emotionally unstable personality disorder (EUPD) is a common mental health disorder, manifesting with a range of chronic and debilitating symptoms, including impaired social functioning, unstable mood, and risky impulsive or self-injurious behaviour. Whilst the exact aetiology has not been fully elucidated, implicated factors seem to include genetic factors, environmental causes such as trauma, and neurotransmitter deficits. The literature suggests that impaired functioning of the endocannabinoid system in key brain regions responsible for emotional processing and stress response may underlie the manifestation of EUPD symptoms. The National Institute for Health and Care Excellence (NICE) 2009 guidelines state that “no drugs have established efficacy in treating or managing EUPD”, and yet, patients are commonly prescribed medication which includes antipsychotics, antidepressants, and mood stabilisers. Here we present a case series of seven participants diagnosed with EUPD and treated with cannabis-based medicinal products (CBMPs). Participants were given an initial assessment and followed up one month after CBMPs prescription. Improvement in symptoms was assessed by the completion of ratified rating scales by the participant and psychiatrist. Our results indicate that CBMPs were effective and well tolerated, as six participants reported a noticeable improvement in their symptoms and functioning. Although promising, further research is needed to ascertain the long-term tolerability, efficacy, and dosing strategy for CBMPs in EUPD.

Effects of Cannabis on PTSD Recovery: Review of the Literature and Clinical Insights

Purpose of Review

Individuals with posttraumatic stress disorder (PTSD) may use cannabis to reduce symptoms yet are also at risk for developing problematic use. This review outlines theories, summarizes recent empirical studies, and discusses clinical implications of cannabis use and PTSD recovery.

Recent Findings

Although naturalistic studies and open trials find a relationship between cannabinoids and PTSD symptom reduction, methodological limitations preclude definitive conclusions. The only randomized controlled trial to date found cannabis had no greater effect on PTSD symptoms than placebo.

Summary

Rigorous studies of the long-term impact of cannabis use on PTSD recovery are needed. Clinicians and researchers must weigh the potential therapeutic effect against the costs and risks associated with long-term cannabis use. Clinicians should consider all available PTSD treatment options, along with client level factors such as the function of cannabis use, motivation to change use, and the potential impact of cannabis on treatment engagement when making clinical recommendations.

Could serum endocannabinoid and N-acylethanolamine levels be important in bipolar disorder?

OBJECTIVES

The endocannabinoid system (ECS) is a critical important neuromodulatory system that interacts with many neurohormonal and neurotransmitter systems in the brain. It plays a pivotal role in emotional responses and mood regulation. The ECS is related with psychotic disorders, depression, anxiety and autism. In this study, we aimed to investigate whether there is any relationship between endocannabinoid and N-acylethanolamine levels with bipolar disorder.

METHODS

Seventy-nine patients with bipolar disorder diagnosis, who are in the euthymic period, were included in the study. Clinical characteristics, symptoms and serum endocannabinoid and N-acylethanolamine levels were compared. Endocannabinoid and N-acylethanolamine levels were evaluated using liquid chromatography-tandem mass spectrometry.

RESULTS

In total of 79 patients, 44 (55.69%) were females and 35 (44.30%) were males. The mean age of the patients was 42.40 ± 1.10 years. Palmitoylethanolamide (PEA) levels were higher and oleoylethanolamide and 2-arachidonyl glycerol levels were lower in patients who had at least one depressive episode during their life-time illness than in patients who had no depressive episode while arachidonyl ethanolamide levels were unchanged.

CONCLUSIONS

PEA levels were correlated with the history and frequency of depressive episodes and the history of depressive symptoms in patients with bipolar disorder.

Cannabis use among U.S. military veterans with subthreshold or threshold posttraumatic stress disorder: Psychiatric comorbidities, functioning, and strategies for coping with posttraumatic stress symptoms

Cannabis use is common among individuals with posttraumatic stress disorder (PTSD) symptoms, but its impact on psychiatric symptoms and functioning in this population is unclear. To clarify the clinical and functional correlates of cannabis use in individuals with PTSD symptoms, we analyzed data from the 2019-2020 National Health and Resilience in Veterans Study, a nationally representative survey of U.S. military veterans. Participants with current subthreshold or full PTSD (N = 608) reported on their past-6-month cannabis use and current psychiatric symptoms, functioning, treatment utilization, and PTSD symptom management strategies. Veterans with subthreshold/full PTSD who used cannabis more than weekly were more likely to screen positive for co-occurring depression, anxiety, and suicidal ideation than those who did not use cannabis, ORs = 3.4-3.8, or used cannabis less than weekly, ORs = 2.7-3.7. Veterans who used cannabis more than weekly also scored lower in cognitive functioning than veterans with no use, d = 0.25, or infrequent use, d = 0.71, and were substantially more likely to endorse avoidance coping strategies, ORs = 8.2-12.2, including substance use, OR = 4.4, and behavioral disengagement, ORs = 2.7-9.1, to manage PTSD symptoms. Despite more psychiatric and functional problems, veterans with frequent cannabis use were not more likely to engage in mental health treatment, ORs = 0.87-0.99. The results suggest enhanced cannabis use screening, interventions targeting risky use, and strategies promoting treatment engagement may help ameliorate more severe clinical presentations associated with frequent cannabis use among veterans with subthreshold/full PTSD.

Coping Motives Mediate the Association of Trauma History with Problematic Cannabis Use in Young Adult Medical Cannabis Patients and Non-Patient Cannabis Users

Background: Despite evidence of the contribution of childhood trauma to the development of problematic cannabis use, its mediating pathways are largely unknown. Given the link between cannabis motives with trauma and problematic cannabis use, motives of use may represent a construct through which trauma impacts problematic cannabis use. Methods: A sample of 339 medical cannabis patient and non-patient young adult users from the Los Angeles area were sampled at baseline and one year later. The current study examined the impact of childhood trauma on problematic use through a variety of cannabis use motives. Results: Controlling for age, socioeconomic status, perceived stress, and baseline problematic use, endorsing the use of cannabis to cope with distress at baseline uniquely mediated the associations between different childhood trauma types (e.g., physical abuse, neglect, sexual trauma) and problematic use one year later. Experience of any childhood trauma was positively associated with coping motives, whereas emotional and physical abuse were positively associated with pain motives, and sexual abuse was positively associated with sleep motives. Using cannabis for coping and increasing attention/focus were also positively associated with higher problematic use, whereas using cannabis for sleep was inversely associated with problematic use one year later. Conclusions: The motives of coping with distress and inattention may represent intermediate constructs through which trauma leads to later problematic cannabis use. Results highlight the need to clarify the pathways between health and non-health-oriented motives and cannabis use over time.

A History of Childhood Maltreatment Has Substance- and Sex-Specific Effects on Craving During Treatment for Substance Use Disorders

RATIONALE

Childhood maltreatment (CM) leads to detrimental mental health outcomes, such as substance use disorders (SUD). This study examined prevalence and severity of all five types of CM with respect to specific substances and sex in treatment-seeking individuals with SUD. The influences of type of CM and symptoms of depressiveness, anxiety, and perceived stress on substance craving at admission as well as craving reduction during SUD treatment were examined.

METHODS

N = 546 patients in treatment for SUD and N = 109 individuals in opioid maintenance treatment filled out questionnaires regarding CM (Childhood Trauma Questionnaire) and psychopathologies. Substance craving was assessed throughout treatment using the Mannheim Craving Scale. Group differences in CM, type of substance and sex were examined. General linear models were applied to examine influences on substance craving.

RESULTS

Higher prevalence and severity of all five subtypes of CM were observed in individuals with SUD compared to the general population. Women were more severely affected by emotional and sexual abuse than men. Patients with cannabis use disorder reported more severe experiences of emotional abuse compared to all other substances. Craving at admission to treatment was influenced by emotional abuse, however, symptoms of depressiveness, anxiety, and perceived stress contributed to craving at admission or craving reduction during treatment.

CONCLUSION

CM relates to SUD and should be incorporated in prevention and treatment of SUD. Underlying mechanisms of the association might relate to impairments in processing and regulation of stress, emotions, and interpersonal relations following a history of CM.

Quality of Life and a Surveillant Endocannabinoid System

The endocannabinoid system (ECS) is an important brain modulatory network. ECS regulates brain homeostasis throughout development, from progenitor fate decision to neuro- and gliogenesis, synaptogenesis, brain plasticity and circuit repair, up to learning, memory, fear, protection, and death. It is a major player in the hypothalamic-peripheral system-adipose tissue in the regulation of food intake, energy storage, nutritional status, and adipose tissue mass, consequently affecting obesity. Loss of ECS control might affect mood disorders (anxiety, hyperactivity, psychosis, and depression), lead to drug abuse, and impact neurodegenerative (Alzheimer's, Parkinson, Huntington, Multiple, and Amyotrophic Lateral Sclerosis) and neurodevelopmental (autism spectrum) disorders. Practice of regular physical and/or mind-body mindfulness and meditative activities have been shown to modulate endocannabinoid (eCB) levels, in addition to other players as brain-derived neurotrophic factor (BDNF). ECS is involved in pain, inflammation, metabolic and cardiovascular dysfunctions, general immune responses (asthma, allergy, and arthritis) and tumor expansion, both/either in the brain and/or in the periphery. The reason for such a vast impact is the fact that arachidonic acid, a precursor of eCBs, is present in every membrane cell of the body and on demand eCBs synthesis is regulated by electrical activity and calcium shifts. Novel lipid (lipoxins and resolvins) or peptide (hemopressin) players of the ECS also operate as regulators of physiological allostasis. Indeed, the presence of cannabinoid receptors in intracellular organelles as mitochondria or lysosomes, or in nuclear targets as PPARγ might impact energy consumption, metabolism and cell death. To live a better life implies in a vigilant ECS, through healthy diet selection (based on a balanced omega-3 and -6 polyunsaturated fatty acids), weekly exercises and meditation therapy, all of which regulating eCBs levels, surrounded by a constructive social network. Cannabidiol, a diet supplement has been a major player with anti-inflammatory, anxiolytic, antidepressant, and antioxidant activities. Cognitive challenges and emotional intelligence might strengthen the ECS, which is built on a variety of synapses that modify human behavior. As therapeutically concerned, the ECS is essential for maintaining homeostasis and cannabinoids are promising tools to control innumerous targets.

The Green Sheep: Exploring the Perceived Risks and Benefits of Cannabis Among Young Military Members and Veterans

Medical and recreational cannabis are becoming more accessible and socially accepted across the United States. Emerging adults (EAs; 18 to 29) are the largest group of cannabis users. Studies have found that veterans are more likely to report cannabis use compared to nonveterans. While research exists on the use levels of cannabis, limited knowledge is available on the perceived risks and benefits of using cannabis among EA military and veteran populations. Helping professionals encounter veterans who use cannabis and must consider military cultural factors and attitudes towards cannabis that may influence or exacerbate cannabis use. We conducted a qualitative study with 23 EA veteran and military members with high-risk substance use and asked about their thoughts on the acceptability, risks, and perceived benefits associated with cannabis. Two qualitative coders used NVivo to find themes following the six steps of thematic analysis. Results provide in-depth understanding of EA military members and veterans' perceptions of cannabis. Overall, we found participants were receptive to using cannabis for pain ailments, mental health issues, and as an alternative to benzodiazepines, opioids, and alcohol. However, they acknowledged restrictions are needed to moderate cannabis use and mitigate negative outcomes. Lastly, participants recognized the incongruence of cannabis use with military job responsibilities and expectations. These findings shed light on potential risk and protective factors related to using cannabis for recreational or medical reasons and should be considered when consulting EA military members and veterans.

Evaluation of Patient Reported Safety and Efficacy of Cannabis From a Survey of Medical Cannabis Patients in Canada

With the medical use of cannabis permitted in Canada since 2001, patients seek to use this botanical drug to treat a range of medical conditions. However, many healthcare practitioners express the need for further scientific evidence around the use of medical cannabis. This real-world evidence study aimed to address the paucity of scientific data by surveying newly registered medical cannabis patients, before beginning medical cannabis treatment, and at one follow up 6 weeks after beginning medical cannabis treatment. The goal was to collect data on efficacy, safety and cannabis product type information to capture the potential impact medical cannabis had on patient-reported quality of life (QOL) and several medical conditions over a 6-week period using validated questionnaires. The 214 participants were mainly male (58%) and 57% of the population was older than 50. The most frequently reported medical conditions were recurrent pain, post-traumatic stress disorder (PTSD), anxiety, sleep disorders [including restless leg syndrome (RLS)], and arthritis and other rheumatic disorders. Here we report that over 60% of our medical cannabis cohort self-reported improvements in their medical conditions. With the use of validated surveys, we found significant improvements in recurrent pain, PTSD, and sleep disorders after 6 weeks of medical cannabis treatment. Our findings from patients who reported arthritis and other rheumatic disorders are complex, showing improvements in pain and global activity sub-scores, but not overall changes in validated survey scores. We also report that patients who stated anxiety as their main medical condition did not experience significant changes in their anxiety after 6 weeks of cannabis treatment, though there were QOL improvements. While these results show that patients find cannabis treatment effective for a broad range of medical conditions, cannabis was not a remedy for all the conditions investigated. Thus, there is a need for future clinical research to support the findings we have reported. Additionally, while real-world evidence has not historically been utilized by regulatory bodies, we suggest changes in public policy surrounding cannabis should occur to reflect patient reported efficacy of cannabis from real-world studies due to the uniqueness of medical cannabis's path to legalization.

Cannabis in the management of PTSD: a systematic review

Introduction

Existing reviews exploring cannabis effectiveness have numerous limitations including narrow search strategies. We systematically explored cannabis effects on PTSD symptoms, quality of life (QOL), and return to work (RTW). We also investigated harm outcomes such as adverse effects and dropouts due to adverse effects, inefficacy, and all-cause dropout rates.

Methods

Our search in MEDLINE, EMBASE, PsycInfo, CINAHL, Web of Science, CENTRAL, and PubMed databases, yielded 1 eligible RCT and 10 observational studies (n = 4672). Risk of bias (RoB) was assessed with the Cochrane risk of bias tool and ROBINS-I.

Results

Evidence from the included studies was mainly based on non-randomized studies with no comparators. Results from unpooled, high RoB studies showed that cannabis was associated with a reduction in overall PTSD symptoms and improved QOL. Dry mouth, headaches, and psychoactive effects such as agitation and euphoria were the commonly reported adverse effects. In most studies, cannabis was well tolerated, but small proportions of patients experienced a worsening of PTSD symptoms.

Conclusion

Evidence in the current study primarily stems from low quality and high RoB observational studies. Further RCTs investigating cannabis effects on PTSD treatment should be conducted with larger sample sizes and explore a broader range of patient-important outcomes.

The short-term impact of 3 smoked cannabis preparations versus placebo on PTSD symptoms: A randomized cross-over clinical trial

IMPORTANCE

There is a pressing need for development of novel pharmacology for the treatment of Posttraumatic Stress Disorder (PTSD). Given increasing use of medical cannabis among US military veterans to self-treat PTSD, there is strong public interest in whether cannabis may be a safe and effective treatment for PTSD.

OBJECTIVE

The aim of the present study was to collect preliminary data on the safety and potential efficacy of three active concentrations of smoked cannabis (i.e., High THC = approximately 12% THC and < 0.05% CBD; High CBD = 11% CBD and 0.50% THC; THC+CBD = approximately 7.9% THC and 8.1% CBD, and placebo = < 0.03% THC and < 0.01% CBD) compared to placebo in the treatment of PTSD among military veterans.

METHODS

The study used a double-blind, cross-over design, where participants were randomly assigned to receive three weeks of either active treatment or placebo in Stage 1 (N = 80), and then were re-randomized after a 2-week washout period to receive one of the other three active treatments in Stage 2 (N = 74). The primary outcome measure was change in PTSD symptom severity from baseline to end of treatment in Stage 1.

RESULTS

The study did not find a significant difference in change in PTSD symptom severity between the active cannabis concentrations and placebo by the end of Stage 1. All three active concentrations of smoked cannabis were generally well tolerated.

CONCLUSIONS AND RELEVANCE

The present study is the first randomized placebo-controlled trial of smoked cannabis for PTSD. All treatment groups, including placebo, showed good tolerability and significant improvements in PTSD symptoms during three weeks of treatment, but no active treatment statistically outperformed placebo in this brief, preliminary trial. Additional well-controlled and adequately powered studies with cannabis suitable for FDA drug development are needed to determine whether smoked cannabis improves symptoms of PTSD.

TRIAL REGISTRATION

Identifier: NCT02759185; ClinicalTrials.gov.

Regulatory Status of Pesticide Residues in Cannabis: Implications to Medical Use in Neurological Diseases

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Movement disorders are the most common neurological category of qualifying conditions in the U.S.

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The number and action levels of regulated pesticides in cannabis differ vastly in 33 states and Washington, D.C.

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Network analysis reveals potential interactions of insecticides, cannabinoids, and seizure at a functional level.

Medical cannabis represents a potential route of pesticide exposure to susceptible populations. We compared the qualifying conditions for medical use and pesticide testing requirements of cannabis in 33 states and Washington, D.C. Movement disorders were the most common neurological category of qualifying conditions, including epilepsy, certain symptoms of multiple sclerosis, Parkinson’s Disease, and any cause of symptoms leading to seizures or spasticity. Different approaches of pesticide regulation were implemented in cannabis and cannabis-derived products. Six states imposed the strictest U.S. EPA tolerances (i.e. maximum residue levels) for food commodities on up to 400 pesticidal active ingredients in cannabis, while pesticide testing was optional in three states. Dimethomorph showed the largest variation in action levels, ranging from 0.1 to 60 ppm in 5 states. We evaluated the potential connections between insecticides, cannabinoids, and seizure using the Comparative Toxicogenomics Database. Twenty-two insecticides, two cannabinoids, and 63 genes were associated with 674 computationally generated chemical-gene-phenotype-disease (CGPD) tetramer constructs. Notable functional clusters included oxidation-reduction process (183 CGPD-tetramers), synaptic signaling pathways (151), and neuropeptide hormone activity (46). Cholinergic, dopaminergic, and retrograde endocannabinoid signaling pathways were linked to 10 genetic variants of epilepsy patients. Further research is needed to assess human health risk of cannabinoids and pesticides in support of a national standard for cannabis pesticide regulations.

From an Alternative Medicine to a New Treatment for Refractory Epilepsies: Can Cannabidiol Follow the Same Path to Treat Neuropsychiatric Disorders?

Although cannabis has been known for ages as an "alternative medicine" to provide relief from seizures, pain, anxiety, and inflammation, there had always been a limited scientific review to prove and establish its use in clinics. Early studies carried out by Carlini's group in Brazil suggested that cannabidiol (CBD), a non-psychotropic phytocannabinoid present in Cannabis sativa, has anticonvulsant properties in animal models and reduced seizure frequency in limited human trials. Over the past few years, the potential use of cannabis extract in refractory epilepsy, including childhood epilepsies such as Dravet's syndrome and Lennox-Gastaut Syndrome, has opened a new era of treating epileptic patients. Thus, a considerable number of pre-clinical and clinical studies have provided strong evidence that phytocannabinoids has anticonvulsant properties, as well as being promising in the treatment of different neuropsychiatric disorders, such as depression, anxiety, post-traumatic stress disorder (PTSD), addiction, neurodegenerative disorders and autism spectrum disorder (ASD). Given the advances of cannabinoids, especially CBD, in the treatment of epilepsy, would the same expectation regarding the treatment of other neuropsychiatric disorders be possible? The present review highlights some contributions from Brazilian researchers and other studies reported elsewhere on the history, pre-clinical and clinical data underlying the use of cannabinoids for the already widespread treatment of refractory epilepsies and the possibility of use in the treatment of some neuropsychiatric disorders.

Cannabis use and posttraumatic stress disorder comorbidity: Epidemiology, biology and the potential for novel treatment approaches

Cannabis use is increasing among some demographics in the United States and is tightly linked to anxiety, trauma, and stress reactivity at the epidemiological and biological level. Stress-coping motives are highly cited reasons for cannabis use. However, with increased cannabis use comes the increased susceptibility for cannabis use disorder (CUD). Indeed, CUD is highly comorbid with posttraumatic stress disorder (PTSD). Importantly, endogenous cannabinoid signaling systems play a key role in the regulation of stress reactivity and anxiety regulation, and preclinical data suggest deficiencies in this signaling system could contribute to the development of stress-related psychopathology. Furthermore, endocannabinoid deficiency states, either pre-existing or induced by trauma exposure, could provide explanatory insights into the high rates of comorbid cannabis use in patients with PTSD. Here we review clinical and preclinical literature related to the cannabis use-PTSD comorbidity, the role of endocannabinoids in the regulation of stress reactivity, and potential therapeutic implications of recent work in this area.

From Enchantment to Disillusion: A Narrative Exploration of Cannabis Use Disorder Among Young Israeli Combat Veterans

Introduction: Substance use is common among military personnel and war veterans, especially combat veterans. Despite substantially high prevalence of cannabis use and Cannabis Use Disorder (CUD) consistently reported among veterans, little is known about psychological factors which may underlie CUD among this population. Methods: In this study, we used narrative analysis in order to interpret retrospective in-depth interviews of combat veterans (N = 12) who were released from mandatory military duty during the past 5 years and currently qualified for a diagnosis of CUD. Participants were recruited from a larger quantitative study were eligible for participation if they screened positive for a diagnosis of CUD according to the Cannabis Use Disorder Identification Test- Revised (CUDIT-R) questionnaire. CUD diagnosis was validated in-person using the cannabis section of the Alcohol Use Disorder and Associated Disabilities Interview Schedule-5 (AUDADIS-5) interview protocol. All interviews were transcribed and coded using the content analysis procedure. Findings: Five main themes were extracted: (a) Traumatic events (b) Attitudes toward cannabis use (c) Combatant identity (d) The role of authority/father figures, and (e) Moral crisis. A meta-theme has been identified, "from enchantment to disillusion," representing a gradual psychological shift from a hopeful, highly motivated stance into the current state of mental rupture and moral injury, which are unsuccessfully compensated by excessive use of cannabis. Conclusions: This study shed light on the etiology of CUD among young combat veterans, highlighting the role of supposed self-medication for trauma and sense of betrayal.