Published 15:53 08.07.11
Latest update 15:53 08.07.11
Should we be treating PTSD with THC?
Women suffering from post-traumatic stress as a result of sexual assaults are being prescribed psychiatric medicines, even though there's plenty of anecdotal evidence that medical cannabis is another potential solution
By Ariela Bankier
D., a 26-year-old woman from the north of Israel, says she began to suffer from nightmares about seven years ago, after her partner raped her. After undergoing various forms of therapy, she thought she had largely put the trauma behind her. Then, two years ago, she chanced to see the rapist not far from her home. The nightmares came swarming back.
"I fell into a depression that went on until not long ago, during which I hardly slept or ate," she says in a quiet voice. "My whole life turned upside down. I left my job. Everything came to a stop. I went back to taking antidepressants and tranquilizers - Cipralex, Lustral and Prozac; sleeping pills that made me addicted. It was a nightmare. There was no way I could get through the day without those pills. Then I discovered cannabis."
Of approximately 6,000 Israelis currently being treated with medical cannabis (aka medical marijuana ), most suffer from chronic pain and terminal illnesses. The therapeutic potential of cannabis has been known for many years and is recognized by the Health Ministry. But many patients - for example, victims of sexual assault who suffer from post-traumatic stress disorder (PTSD ) and have a psychiatric recommendation for treatment with medical cannabis - encounter bureaucratic obstacles.
A year and a half ago, Dr. Yehuda Baruch - the chair of the Health Ministry's advisory board for medical cannabis - recognized the effectiveness of the substance for PTSD sufferers. Within a year, 142 requests by such patients for treatment were approved. Dozens of soldiers who suffer from PTSD as a result of their army service were, and continue to be, treated with medical cannabis, with the authorization and support of the Health Ministry and the Ministry of Defense. However, victims of sexual assault have been left out in the cold.
For D., marijuana is not a drug but a medicine. "When I smoked, I didn't need medicines," she says. "It didn't make my life good and beautiful, but it did make it bearable." She now shuns the array of medicines and sleeping pills she took because of the side effects. "If you take sleeping pills, you will bring yourself into sleep mode, you will succeed in getting yourself into bed and shutting off the light, but in the morning you are not the same person. You don't function. The quantity of pills I need in order to fall asleep will turn me into a zombie the next day. My brain is erased; people speak to me but I don't function. How can you live like that? How can you work like that, study, go out of the house, communicate with people?
"I refuse to take antidepressants because of the huge amount of weight I put on, and which I was able to shed only after I stopped taking them," she adds. "They also gave me constant stomachaches, made me nauseous and itchy, and caused dry skin and headaches. That's what life with medicinal drugs is like. So, yes, I'm not depressed. I don't want to die, but I also don't want to live. I'm not me, I don't feel anything, I'm some kind of robot - not happy, not sad, not anything. I am a straight line. It's not a life."
In June 2010, D. and the psychiatrist who was treating her requested a permit for the use of medical cannabis from the Health Ministry. A year later, she is still waiting for an answer. With no alternative, she smokes cannabis obtained illegally. "I am not a criminal," she says. "I need treatment and I can't go back to the serious side effects, which only make things worse."
The cannabis is effective, but fear of the police leaves her in a constant state of anxiety. "These days, most of my nightmares have to do with the police arriving and entering my home," D. says. "It's like rape, as though this is the only safe place I still have but it's not actually safe."
Perchance to dream
Tens of thousands of Israelis are afflicted by a wide variety of traumas every year, caused by everything from battle fatigue, terrorist attacks and road accidents to life threatening diseases. And about 3,000 sexual assaults are perpetrated each year. A small percentage of people, unable to liberate themselves from the trauma, are classified as suffering from PTSD. The conventional treatment in hospitals fuses psychology - in the form of cognitive therapy techniques - with psychiatric medicines, including antianxiety medications, sleeping pills and antidepressants. In recent years, researchers around the world have begun to probe more natural treatments, notably medical marijuana. New Mexico, for example, has passed legislation authorizing medical cannabis for soldiers who returned from a tour of duty in Iraq or Afghanistan suffering from PTSD. A number of interesting studies have been carried out on this subject in Israel. Prof. Rafael Meshulam, an Israel Prize laureate for chemistry and one of the country's leading experts in medical cannabis, and Dr. Irit Akirav, from the Department of Psychology at the University of Haifa, have shown, in separate research, some of the marked advantages of the treatment. "At this stage we are talking only about rats," Dr. Akirav explains, "but the model is relevant for humans, too."
According to Prof. Meshulam, "The active material in marijuana, tetrahydrocannibinol (THC ), emulates activity of materials that are bound up with an important system in the body - the endocannabinoid system. This system plays a critical role in regulating proper eating functions and various mental states, including forgetting. Forgetting is not necessarily something negative. If you enter a department store where there are a thousand people, do you want to remember what each of them looked like? Of course not. It's the same with trauma. What is post-trauma, actually? Something terrible happened and left a very strong impression. A week passes, a month passes, and it doesn't go away. You are unable to forget."
The experiments conducted by Prof. Meshulam and his colleagues were based on administering medical cannabis to mice that had been exposed to a trauma (electric shock ) after their endocannabinoid system was neutralized. The results were clearly positive. The hypothesis was confirmed in subsequent experiments, including a famous experiment carried out by Dr. George Fraser, a Canadian psychiatrist with abundant experience in treating soldiers with PTSD. "A significant improvement was observed in 70 percent of the soldiers who took part in that research, particularly in regard to their sleep," Prof. Meshulam notes. "And why do we examine forgetting and sleep in particular? Because they are essential. One of the most terrible phenomena among PTSD sufferers is that they are unable to sleep: They are afflicted by nightmares and are afraid to fall asleep."
In a similar experiment using rats, Dr. Akirav examined the effect of medical cannabis on a mechanism known as "extinction learning," which serves humans and animals to overcome past trauma. In this experiment, the medical cannabis is injected directly into the part of the brain called the amygdala, which is responsible for emotional memory and the sensation of fear. The rats were also exposed to additional pressure, resembling the permanent stress to which post-trauma patients are subject.
"The medical cannabis helped the rats with extinction learning, despite the trauma and the additional pressure," Dr. Akirav says. "That is extremely important, because researchers and psychiatrists maintain that in human beings who develop post-trauma, something has gone awry in the extinction learning mechanism - that is, they do not succeed in learning that something that was once dangerous is now safe." She emphasizes that the aim of treatment with medical cannabis is not to generate a high or a state of euphoria. "It is a tool," she explains. "The animals do not get a high, nor is their memory completely erased. The aim is simply to influence the element in the emotional memory that is responsible for extinction learning."
More dangerous and addictive
Cannabis is a medicine in every respect, Prof. Meshulam says. He does not understand the reluctance of many psychiatrists to make use of the substance on the grounds that it is dangerous and addictive. "The great majority of them are simply uninformed, period," he believes. "With psychiatric drugs, it's also hard to know what will help who, because it's hard to know which mechanism has gone wrong and which medicine will help. But to say marijuana can't help is from sheer lack of knowledge."
Even though the Health Ministry is aware of the findings of the experiments conducted in Israel and abroad, patients now face increasing obstacles instead of benefiting from solutions. "It is amazing that for my post-trauma I easily - and without unnecessary arguments - get hard drugs such as opiates," says N., a 27-year-old woman from the south of the country who was a victim of sexual assault. "I call it medical heroin, because there isn't much difference between the heroin that's sold on the street and the OxyContin that is prescribed for me. I also get sleeping pills from the benzaprine family, and for dessert I am offered Ritalin. The paradox is that all these medicines are far more dangerous and addictive than marijuana."
The situation is "absurd," says Dr. Ilya Reznik, an expert on the subject and medical director of the Israel Institute for Diagnostic Neuropsychiatry. "Cannabis was approved for post-trauma [treatment] in the past, and then suddenly Dr. Baruch demanded that those applying for approval for post-trauma treatment be recognized as disabled by the National Insurance Institute or by the Defense Ministry, and show proven experience with at least three psychiatric drugs for a very long period - at least half a year with each drug. He also demanded that we refer to cannabis only those patients who are resistant to all the other drugs, and that cannabis constitute a third- or fourth-line treatment for post-trauma. He was actually stipulating far harsher conditions than those demanded by clinical experiments, because cannabis is no more than a medicinal herb, and you can't compare a medicinal herb to Prozac and its like, which had all the wisdom of the scientific world invested in their development."
For whom is cannabis suitable?
Reznik: "Cannabis is suitable for intermediate cases; there is no point demanding that it be used only in the hardest cases, in which no medicine helps. That is just wrong. People diagnosed with cancer receive cannabis straightaway. So why, in cases of post-trauma, is it necessary to wait for the most difficult cases before they are ready to allow its use, if at all? The Health Ministry's approach in this matter is insensitive and without any scientific basis - and I say this on the record, because Dr. Baruch and I talked about it in several scientific conferences and I told him then that what the ministry is doing is not right. What if someone does not want to be officially categorized as disabled? Some people are ashamed to go before committees. Does that mean they are not entitled? That cannot be a Health Ministry criterion."
What do your physician colleagues say?
"On this issue, the medical establishment is divided into two: 95 percent are neutral-to-negative about cannabis, and the rest are neutral-to-positive. No more. Why? It's conservatism. They were always taught that cannabis is bad, that cannabis is a drug, and the moment they hear the word 'cannabis' they see handcuffs looming on the horizon. So they run from it.
"Very few in Israel have experience with medical cannabis. Yehuda Baruch allows himself to set criteria, but he says, 'Persuade me, I am receptive.' He is not a bad person - we have friendly relations - and he is open to suggestions, but the criterion he set is not based on scientific data, period."
Like a walking zombie
"We do not get authorization," D. says. "Apparently only men get such authorization for PTSD. We women are not heroic soldiers who were traumatized while trying to defend the homeland. It's only now that I understand that I am a second-class citizen: I am a woman, I am the victim of a sexual assault, I suffer from depression, but I am apparently not as good as someone who has a backache."
The Health Ministry says no more permits are being issued for the use of medical cannabis in post-trauma therapy, unless the patient is also suffering from a disease that might justify its use (see box ). Disabled army veterans who received authorization in the past are continuing with cannabis therapy but are loath to be interviewed, even anonymously, for fear they will lose the authorization.
One former soldier who did agree to speak on the record is Avraham Sherwood, who was wounded in an incident in which two armored personnel carriers were destroyed and 13 soldiers killed in attacks by Palestinians in the Gaza Strip on successive days in May 2004. He saw his buddies killed and since then has suffered from physical problems and PTSD. "My previous doctor was dead set against the use of marijuana," Sherwood says. "In every meeting he would just give me a prescription for something new or raise the dosage of what I was taking. The problem with these medicines is they cause extreme side effects. They contain cortisone, you start to put on weight, everything is stored up in the body, your face bloats and you look like a walking zombie.
"The antipsychotic drugs cause all kinds of stomach problems - to this day I suffer from heartburn because of them," Sherwood adds. "From my point of view - I say only from my point of view, I don't know about other people - the psychiatric drugs failed to treat my PTSD. Then one day a friend saw that I was walking around with a whole case of medicines - for morning, afternoon and evening - and suggested that maybe I should get a second opinion. That's how I got to Dr. Baruch and told him I wanted to cut down the medicinal dosage and start functioning again." According to Sherwood, Dr. Baruch - the same Dr. Baruch who is preventing other PTSD victims from getting medical cannabis - was his salvation. "From my point of view, the man is a saint," Sherwood says. "He saved me. He asked me if I wanted to try medical marijuana, and I got very uptight. I was afraid of the side effects, things that I now know are nonsense, but which absolutely made me shake when he said the word 'marijuana.' My previous doctor had totally frightened both me and my father: He said I would become addicted and that I would move on to hard drugs, to heroin. But actually I had already used heroin, because the pills I was taking contained morphine - and what is morphine?"
Despite his fears, Sherwood decided to try medical cannabis for a month. "My life changed completely," he says with visible emotion. "My face went back to what it was, I lost weight, I became a human being again. People are afraid, but there are problems caused by taking so many medicines that it's hard to know what a person is suffering from. In the meantime, I am with marijuana. Dr. Baruch left me with one psychiatric drug, which he says is keeping me in balance for now, and he will gradually lower its dosage. I went down from 17 medicines to five, including those against pains, against the nerve damage in my hand and against heartburn."
Dr. Baruch's response makes no mention of Sherwood, but it can be gleaned from it that, even if one of his patients received authorization to be treated with medical cannabis, this was not due to post-traumatic symptoms but to some other medical problem.
"Not one of [my] private patients received authorization for treatment with medical cannabis for PTSD," Dr. Baruch stated. "As a rule, I do not take patients who want treatment with medical cannabis in my private clinic. To the best of my knowledge, only three patients who went through my private clinic in the six years during which I have dealt with the subject have received authorization to use medical cannabis. The vast majority of the 142 people [who received authorization] are requests from other psychiatrists."
In the wake of Sherwood's favorable reaction and the positive experience that soldiers suffering from PTSD have had with medical cannabis, it is difficult to understand the refusal of the Health Ministry to provide the same effective treatment to victims of sexual assault - who suffer from equally debilitating post-traumatic symptoms. That is exactly the question that L. asked for many long months. A self-employed woman in her thirties from the north of the country, she has been suffering from PTSD for years as a result of childhood sexual assault.
"That is how I grew up. I don't know the meaning of being normal," she says. "I know what it means to be depressed and have nightmares and anxieties and feel uncomfortable among people. For years I didn't tell anyone. It took many years before I told my parents, and they were very uncomfortable with it. It's the kind of thing you don't talk about at home. All the talk is about my problems, and it's hard for them to make the connection. I had psychological therapy but nothing helped. It's not easy." She falls silent.
After composing herself, L. continues: "About six years ago, someone gave me medical cannabis, which he had, and it really helped me. Suddenly I was able to obtain a master's degree, find a job and have a social life. It was like magic. [Previously] I had a great many nightmares - I woke from sleep shouting - and it helped me stop being wound up all the time."
She also continued to receive medicinal treatment. "My doctor kept switching my drugs. I would tell her that they caused side effects and that I felt no change, but she would say, 'Take this, it will help you' - she just wasn't listening to me. Two years ago, I looked at all kinds of websites about medical cannabis and I saw that it was used in treatment for PTSD. Hey, I thought, this can really help me. Then I found Dr. S. and told him about my condition. He said medical cannabis could help me a great deal."
Despite the unreserved recommendation of Dr. S. - an expert in post-traumatic therapy - L. discovered that the Health Ministry wasn't about to come to her aid. "There were delays for six months," she remembers. "Dr. S. kept telling me he wanted to help but couldn't, because of all kinds of restraints imposed on him from above. In the end he got a green light to recommend me, and then another half a year went by. In the meantime, other people told me they had received authorization, and it drove me crazy.
"People tell me, 'What's the problem? Tell them you have cluster headaches. What, you don't know you have them? They're a terrific thing. There are no tests for it. You just say you have the symptoms that you read about on the Internet and try. They'll give you Voltaren, you'll take it a couple of times and then throw it away and say it doesn't help. Then you ask for medical cannabis.' So, do I have to lie to get proper medical treatment?"
This month, L. was informed that her request has been approved. That's good news for her, but many patients - including the other women interviewed for this article - are still waiting.
An egregious by-product of the Health Ministry's confused policy is the involvement of people who exploit patients' distress for their own personal benefit. One of the people L. encountered while looking for someone to help her was a man who presented himself as a volunteer with the Health Ministry. The ministry says volunteers are an integral part of its work, but it's not clear what training they get, whether background checks are run on them and what medical secrets they have access to.
According to L., the volunteer told her he could help her get a speedy authorization, but he wanted a quid pro quo. "He told me, 'You will have to come here and we will have to interview you.' I asked him what he was talking about. 'I have a doctor,' I said, 'I have a recommendation, I have to know whether you can help me or not.' He replied, 'Yes. Maybe I will come to your place.' In short, I understood that things were heading in an unpleasant direction."
A tape recording of their conversation makes it clear that the unpleasant direction was heading toward sexual favors:
Volunteer: "Do you hear? Like I did with a woman friend of mine who suffered from depression ... I got her a permit, the good life, I pampered her."
L.: "But I don't like people to touch me."
Volunteer: "You like my work."
L.: "No, no, I don't. I don't like it when people touch me."
Volunteer: "It's not about getting laid. I told you already back then, I don't want to sleep with you."
L.: "I can't..."
Volunteer: "Whatever you like. You can smoke before, so you'll be in a good mood."
L.: "What does this have to do with it? There is an authorization that gets signed by the ministry, no? So what's the connection?"
Volunteer: "Fine, e-mail me your request."
A spokesperson for the Health Ministry said in response: "That man is no longer a volunteer with us. At this stage, the ministry's work [in the area of medical cannabis] is based on volunteers, because until late 2010 there was no budgeting for professional staff. In the 2011 budget we expect to receive budgetary allocations to hire manpower, but not for permanent positions. Volunteers will therefore continue to work in the ministry; volunteering is valuable as such for patients."
One big mess
"Many people ask me why I don't pretend to have a disease in order to get cannabis," D. says. "There may be some people who do that, but I don't want to. I am afraid as it is, because I am treating myself, albeit under medical supervision - my psychiatrist knows that I smoke [cannabis] and accepts it and understands the situation."
All the women who were interviewed for this article say that, at one stage or another, they were told they would have to wait for the results of an experiment being conducted by the Health Ministry to examine the effect of medical cannabis on PTSD patients; any information about the experiment is shrouded in mystery.
According to a psychiatrist who asked for anonymity, the experiment is problematic: "Patients were told that if they wanted authorization, they should take part in the study," he says. "But it is wrong and illegal to say anything like that. And then, after some had agreed to take part, they were told, 'Just a minute, we are still organizing a group. Wait. We'll let you know.' One big mess.
"Yehuda Baruch decided to do a study precisely on post-trauma patients. I say that it is a conflict of interest for the regulator to conduct a study. The situation now is that people can't get authorization until the study is completed, and it hasn't yet begun. In the meantime, people are left dangling, with no answer, and are suffering."
D. is left feeling despair about the situation: "At last we found something that helps, but we are not getting it," she says. "From their point of view, I guess it's preferable for us to be in a situation of 'Another second and I will kill myself,' than 'Things are good but I am a criminal.' To whom are women like me - who had such terrible things done to them by men - supposed to turn in order to get the medicine they need? To drug dealers! It's like going back into this circle of scary psychopathic men who, in a second, can change totally. It's going to criminals to get medicine. Totally absurd."