This article was cowritten by Jordan Tishler MD, and Amanda Reiman, PhD MSW, of New Frontier Data.
Veterans of the armed services, in the United States and around the world, have been using cannabis for pain and PTSD symptoms since at least the Vietnam War. They have accumulated lifetimes of experience with this medication and, as a group, demonstrate the best, and worst, of what cannabis can do.
PTSD Rates In Veterans
PTSD in veterans has real consequences and negative outcomes for them and their families. Incidence of PTSD in the US in veterans is 13% vs. 6% in the general population (1). PTSD rates can vary by war and population, with women reporting higher rates of PTSD. Suicides and suicide-attempts in veterans are 1.5x higher than the general population (2). Alcohol is the primary substance for 65% of veterans entering treatment, nearly twice the rate as civilians. According to the 2017 National Survey on Drug Use and Health, 57% of veterans reported using alcohol in the past month compared to 51% in the general population (3). The U.S. Census Bureau American Community Survey reports that the divorce rate for members of the military is almost twice the national average (4).
Cannabis Use In Veterans
In 2019-2020, 12% of veterans reported using cannabis in the past 6 months and over 20% of veterans aged 18-44 reported past 6 month use, which is significantly higher than the general population (5). While this could imply that veterans are “early adopters” of cannabis medicine and are getting benefit from it, it could also point to increased problematic use.
Sadly, from a lack of knowledge on the part of clinicians and a general distrust among veterans for the medical establishment, most veterans opt to explore cannabis with the guidance of other veterans, not medical personnel. Certainly peer-support is helpful in many instances, but in others, such as cannabis treatment, it often propagates lore and misinformation.
While there is good evidence to support the use of cannabis for veterans (6-7), including those with PTSD (7-8), there is also good evidence that doing so without medical guidance leads rapidly to overuse and downstream consequences in the veteran population (9). Veterans who use cannabis with careful, medically guided attention to dose, frequency, and method of delivery, along with adjunctive care like psychotherapy and conventional medications do better (9). Bypassing this care is harmful to veterans.
Veteran’s advocacy groups often focus their attention on gaining broad access to cannabis as “medicine” while circumventing normal medical supervision. As with any medication, use without guidance is a very likely recipe for inappropriate and perhaps injurious use.
Conflict of Interest In the Cannabis Industry
Much of the effort to bypass the medical practitioner is motivated by the cannabis industry (11). Inherently there is a conflict between the business interests of the companies and health care. In healthcare our goal is always to use the least medication necessary to achieve benefit. Using more only leads to side effects and other problems like dependence or addiction. Of course, the industry would like people to use more, and development of dependence or Cannabis Use Disorder is only to their benefit, like the cocaine in Coca-Cola of yore.
Recently, legislation has been proposed at the state level to allow veterans to bypass healthcare. Typically this seeks to conflate a financial determination of “disability” by the Veteran’s Administration with a medical diagnosis, and assumes therefore that a simple diagnosis is a stand-in for ongoing evaluation and treatment by a health care practitioner. A VA determination of disability is a financial decision made by an administrator, not a clinician, that solely has value for determining VA benefits. Disability is neither a diagnosis nor does it reflect a patient’s care or ongoing treatment. Furthermore, any current illness is an ongoing process subject to evolution and development worthy of care and guidance from medical professionals. It is inappropriate to allow or disallow medical care (with cannabis) on the basis of an administrative determination without reference to current and ongoing condition.
One bill (12), that is repeatedly introduced to the legislature by veteran advocacy groups, illustrates this point vividly. “…such a veteran shall not be required to receive a diagnosis from a registered healthcare professional,” very succinctly demonstrates the intent of this bill to side-step proper medical care. This is very much in the interest of the cannabis industry. It is very much not in the best interests of medical patients and puts them at risk of harm to their health from the very system intended to help them.
Veterans, like all patients, deserve the best healthcare options. Bills like this undermine their care and they deserve better. It is incumbent on healthcare professionals to learn the science and medicine of cannabis and cannabinoid care, so that we can provide for these deserving patients. Further, it is on us to advocate for the interests of veterans, as with all patients, for laws and regulation that best serve their needs, including access to medicine with proper guidance, and without interference from misinformation and industry greed. This is the mission of ACS.
Dr. Tishler is a Cannabinoid Specialist physician. He is the President of the Association of Cannabinoid Specialists & faculty at Harvard Medical School & Mass General Brigham. He was awarded Clinician of the Year by Americans for Safe Access & Marfan’s Society. He is advisor to MA Cannabis Commission & Council for Federal Cannabis Regulation.
Amanda Reiman, PhD is the Chief Knowledge Officer for New Frontier Data. Dr. Reiman earned her PhD in Social Welfare from the University of California and conducted one of the first research studies on medical cannabis patients and the use of cannabis as a substitute for alcohol and other drugs. Having studied cannabis use and policy for over 20 years, she is an internationally recognized cannabis expert and public health researcher. Formerly the in-house cannabis expert for the Drug Policy Alliance, she has written for/been quoted in numerous national and international publications as well as peer reviewed academic journals and several textbooks.
1. Hill and Ponton (nd). PTSD and Veterans: Breaking down the statistics. www.hillandponton.com/veterans-statistics/ptsd
2. Kalvesmaki A, Chapman A, Peterson K, et al. (2022). Analysis of a National Response to a White House Directive for Ending Veteran Suicide. Health Services Research. https://pubmed.ncbi.nlm.nih.gov/35238027/
3. National Institute on Drug Abuse (nd). (2019). Substance Use and Military Life. nida.nih.gov/publications/drugfacts/substance-use-military-life
4. Channel, J. (2023). From being in the military to tending bar, these are the types of jobs and individual occupations with the highest divorce rates. www.lendingtree.com/personal/divorce-rate-jobs-occupations-study
5. Hill, M. L., Loflin, M., Nichter, B., Norman, S. B., & Pietrzak, R. H. (2021). Prevalence of cannabis use, disorder, and medical card possession in U.S. military Veterans: Results from the 2019-2020 National Health and Resilience in Veterans Study. Addictive Behaviors, 120, 106963. https://doi.org/10.1016/j.addbeh.2021106963
6. Walsh, Z., Gonzalez, R., Crosby, K., S. Thiessen, M., Carroll, C., & Bonn-Miller, M. O. (2017). Medical cannabis and mental health: A guided systematic review. Clinical Psychology Review, 51, 15–29. https://doi.org/10.1016/j.cpr.2016.10.002
7. Raymundi, A. M., Da Silva, T. R., Sohn, J. M. B., Bertoglio, L. J., & Stern, C. A. (2020). Effects of Δ9-tetrahydrocannabinol on aversive memories and anxiety: A review from human studies. BMC Psychiatry, 20(1). https://doi.org/10.1186/s12888-020-02813-8
8. Zabik, N. L., Rabinak, C. A., Peters, C. A., & Iadipaolo, A. (2023). Cannabinoid modulation of corticolimbic activation during extinction learning and fear renewal in adults with posttraumatic stress disorder. Neurobiology of Learning and Memory, 107758. https://doi.org/10.1016/J.NLM.2023.107758
9. Loflin, M. J. E., Babson, K., Sottile, J., Norman, S. B., Gruber, S., & Bonn-Miller, M. O. (2019). A cross-sectional examination of choice and behavior of veterans with access to free medicinal cannabis. American Journal of Drug and Alcohol Abuse, 45(5), 506–513. https://doi.org/10.1080/00952990.2019.1604722
10. Rehman, Y., Saini, A., Huang, S., Sood, E., Gill, R., Yanikomeroglu, S., … Yanikomeroglu, S. (2021). Cannabis in the management of PTSD: a systematic review. AIMS Neuroscience, 8(3), 414–434. https://doi.org/10.3934/Neuroscience.2021022
11. Haug, N. A., Kieschnick, D., Sottile, J. E., Babson, K. A., Vandrey, R., & Bonn-Miller, M. O. (2016). Training and Practices of Cannabis Dispensary Staff. Cannabis and Cannabinoid Research, 1(1), 244–251. https://doi.org/10.1089/can.2016.0024
12. Bill H.119 193rd (Current) “An Act further defining eligibility for medical use marijuana” https://malegislature.gov/Bills/193/H119