MEDICAL CANNABIS AS TREATMENT FOR CHRONIC COMBAT PTSD€¦ · treatment program for parcipants suffering from PTSD has been under my charge in Israel. Currently due to Ministry of

MordechaiMashiah,MD,MHA.

DeputyDirector,AbarbanelMentalHospital,Israel

PromisingResultsinanOpenPilotStudy

MEDICALCANNABISASTREATMENTFORCHRONIC

COMBATPTSD

Patients Out of Time Conference,

Tucson, Arizona April 28, 2012

INTRODUCTION IamtheDeputyDirectoroftheAbarbanelMentalHospital‐thelargestmentalhospitalinIsraelwith300+beds

 Forthepast3yearsthelicensingofthecannabistreatmentprogramforparMcipantssufferingfromPTSDhasbeenundermychargeinIsrael.

 CurrentlyduetoMinistryofDefenserestricMonsastocombat‐relatedPTSDoutofthe~8,000totalpaMentstreatedwithcannabisinIsraelthereareonly~200parMcipantsreceivingcannabistotreatchronicPTSD.

DSM‐IV‐TRCRITERIAFORPTSD

Adisorderbasedonseveralcriterion

experiencedoverMme.

 ThepersonhasbeenexposedtoatraumaMceventinwhichbothofthefollowinghavebeenpresent:

 Thepersonhasexperienced,witnessed,orbeenconfrontedwithaneventoreventsthatinvolveactualorthreateneddeathorseriousinjury,orathreattothephysicalintegrityofoneselforothers.

 Theperson'sresponseinvolvedintensefear,helplessness,orhorror.

A B C DE F

STRESSORCRITERION

A

Thetrauma0ceventispersistentlyre‐experiencedinatleastoneofthefollowingways:1. RecurrentandintrusivedistressingrecollecMonsoftheevent,includingimages,thoughts,orpercepMons.2. Recurrentdistressingdreamsoftheevent.3. AcMngorfeelingasifthetraumaMceventwererecurring(includesasenseofrelivingtheexperience,illusions,hallucinaMons,anddissociaMveflashbackepisodes,includingthosethatoccuruponawakeningorwhenintoxicated).4. IntensepsychologicaldistressatexposuretointernalorexternalcuesthatsymbolizeorresembleanaspectofthetraumaMcevent.5. PhysiologicreacMvityuponexposuretointernalorexternalcuesthatsymbolizeorresembleanaspectofthetraumaMcevent

A B C DE F

INTRUSIVERECOLLECTIONCRITERION

B

Persistentavoidanceofs0muliassociatedwiththetraumaandnumbingofgeneralresponsiveness(notpresentbeforethetrauma),asindicatedbyatleastthreeofthefollowing:1.  Effortstoavoidthoughts,feelings,orconversaMons

associatedwiththetrauma2.  EffortstoavoidacMviMes,places,orpeoplethatarouse

recollecMonsofthetrauma3.  Inabilitytorecallanimportantaspectofthetrauma4.  MarkedlydiminishedinterestorparMcipaMoninsignificant

acMviMes5.  Feelingofdetachmentorestrangementfromothers6.  Restrictedrangeofaffect(e.g.,unabletohaveloving

feelings)7.  Senseofforeshortenedfuture(e.g.,doesnotexpectto

haveacareer,marriage,children,oranormallifespan)

A B C DE F

CRITERION

C AVOIDANT/NUMBING

Persistentsymptomsofincreasingarousal(notpresentbeforethetrauma),indicatedbyatleasttwoofthefollowing:1.  Difficultyfallingorstayingasleep2.  Irritabilityoroutburstsofanger3.  DifficultyconcentraMng4.  Hyper‐vigilance5.  Exaggeratedstartleresponse

A B C DE F

HYPERAROUSALCRITERION

D

DuraMonofthedisturbance(symptomsinB,C,andD)ismorethanonemonth.

A B C DE F

DURATIONCRITERION

E

Thedisturbancecausesclinicallysignificantdistressorimpairmentinsocial,occupaMonal,orotherimportantareasoffuncMoning.

A B C DE F

FUNCTIONALSIGNIFICANCECRITERION

F

Acute:IfduraMonofsymptomsislessthanthreemonthsChronic:IfduraMonofsymptomsisthreemonthsormoreWithorWithoutdelayonset:Onsetofsymptomsatleastsixmonthsaherthestressor

DSM‐IVPTSDSpecify if:

Specify if:

CLINICALADMINISTEREDPTSD(CAPS)

CAPS

• ThisisaniniMalself‐reportsymptomchecklist.• ItcoversallkindsofPTSDsymptoms.• Theself‐reportchecklistisusedbythecliniciantoguidetheinterviewfortheassessment.• CAPShasbecomethestandardofPTSDassessmentbecauseitgivesclinicianstheabilitytofocusonthemosteffecMveareasoftreatment.

BaselinePTSDinthisstudy: Studysymptomseverity(CAPSscore)washigh:(97.7+/‐13.3)

 Israelisastressfulanddenseplacewithmanywarsandterroristajacks.AsaresultwehavemanyvicMmsofPTSD.IbelievethebaselineforPTSDisprobablyhigheringeneralinIsrael.

 ThesewerealreadywellestablishedchronicandseverePTSDsufferers.

PTSDINISRAEL

TheefficacyofcurrentlyavailablemedicaMonsinthetreatmentofchroniccombatpost‐traumaMcstressdisorder(PTSD)isvariable,withsomepaMentsnotachievingremission.• ThisopenpilotstudywasdesignedtotesttheeffectsofsmokedcannabisonsymptomsofchroniccombatPTSD.

OUROBJECTIVE:REMISSION

 EnrollmentProfileAsmallnumber(N=29)ofIsraelimale,combatveterans,diagnosedwithPTSD

•  bytheIsraelDefenseForcePTSDUnit•  bytheMinistryofDefenseRehabilitaMonDivision.

 Assessments• AssessmentsincludedPTSDsymptomseverityusingthe(CAPS)interview

•  aself‐assessmentofqualityoflife(QOL)(partofCAPS)•  aclinician‐assessmentofclinicalimprovement.

METHODOLOGY(2008)

or

 Howourpar0cipantsusedCannabis?Smokedmedicalindicacannabisofroughly23%THCandless

than1%CBDwasdispensedtothesubjects:•  atanamountofnomorethan100gramspermonth(basedontheirlicense’slimitandsetatahighleveltothwartunduedistress)

•  Cannabiswasaddedtosubjects'standingtreatment•  SubjectswereinstructedtosmokethecannabisdailyatMmes,frequenciesandamountsoftheirownchoosingunMltheyfeltrelaxed.

 Followup:whatwelearned?CAPSassessmentswereconductedbythePaMent’sPsychiatrist:

•  Atonset,andthenatanaverageof:•  4.3months,(+/‐3.3months),•  7.6months(+/‐2.7months),•  11.3months(+/‐2.9months).

METHODOLOGY(2008)

MEDICALCANNABIS

 29startedthestudy. 26completedthesecondCAPS 25completedthethirdCAPS 10completedthefinalCAPS

PRELIMINARYRESULTS

Whathappenedfollowingcannabisuse? Onaverage,symptomreducMonintheremaining

26subjectswasseeninthesecondCAPSassessment:

PRELIMINARYRESULTS

CAPSAssessment AverageDura0onsincelastCAPSin

Months

AverageCAPSGlobal

SeverityScore*

Baseline ‐ 97.7±13.3

2 4.3±3.3 60.3±20.1

3 7.6±2.7 57.0±20.6

4 11.3±2.9 53.7±18.3

* CAPS Global Severity score of 50 is diagnostic cut-off for moderate PTSD

 UseofmedicalcannabiswasassociatedwithareducMoninPTSDsymptomsinthisopen‐labelpilotstudy.

 Largerstudiesusingrandomized,double‐blindmethodologyareneededtodemonstrateacausalrelaMonship.

 Resultsshowthataher:4.3,7.6and11.3months,paMentssMllhadmoderatetoseverePTSD.

CONCLUSIONS

 AddiMonalareasofstudyinclude: IdenMfyingtheacMveingredientsin

cannabisthathelpwithPTSD Establishingappropriatedoseand

duraMonoftreatment Determininghowcannabisreducesthe

needforothermedicaMons Clarifyingrisksofabuseandotherlegal

aspectsofmedicalcannabisuse.

FUTURERESEARCH

WHATWEAREDOINGTODAYIbelievecannabiscanbeaneffec0vepartofaholis0ccaretreatmentinourclinics Wehavebegunplanninganewdouble‐blindrandomizedcontrolledtrialbasedontherequirementsputforthbyourMinistryofRehabilitaMon(partofourMinistryofDefense)mandaMng:clinicaltrialstoestablishcausalitybetweencannabisastreatmentandPTSD. WehavebegunplanningaretrospecMvestudytoassessthereducMonofmedicaMoncostanduse.

ContactInforma0on:MordechaiMashiah,MD,MHA.DeputyDirectorAbarbanelMentalHealthCenterBatYamIsraelTelephone(fromtheUSA):972.50.626.56.38Email:[email protected]

QUESTIONS/COMMENTS?

Thank you very much and Shalom