1. Dr. Nick Salamie PharmD, RPh
PTSD & Cannabis
Dr. Nick Salamie PharmD, RPh

2. Post Traumatic Stress Disorder (PTSD)
Mental Health Condition
10% of US population
Symptoms
Intrusive Memories
Avoidance
Negative changes in thinking and mood
Changes in physical and emotional reactions
Complications
Quality of Life Destroyed
Depression/anxiety
Substance abuse
Suicidal thoughts/attempts
-Post traumatic stress disorder, also referred to as PTSD, is a mental health condition that’s triggered by a terrifying event by either experiencing it or witnessing it.
- It is estimated that over 10 percent of the US population will experience some PTSD symptoms in their life.
Symptoms of PTSD may start within one month of a traumatic event, but at times they may not appear until years after the event. Symptoms vary from person to person and they can interfere with your ability to perform normal daily tasks.
Symptoms may include:
Intrusive memories which may include Recurrent unwanted memories of the traumatic event, Flashbacks, nightsmares, distress from triggers that remind you of the event.
Avoidance may include avoiding thinking or talking about the event. Or avoiding people, places and activities that remind you of the traumatic event.
Symptoms of negative changes in thinking and mood may include: negative thoughts, hopelessness, memory problems, problems with relationships, feeling detached, lack of interest in once enjoyable things,or feeling numb.
Changes in physical and emotional reactions may include being easily startled or frightened, always being on guard, self-destructive behavior, trouble sleeping, trouble concentrating, irritability, and overwhelming guilt or shame.
PTSD can complicate a persons life and be quite the disruption. It can increase the risk of other mental health issues like depression and anxiety, substance abuse and suicidal thoughts or suicide attempts.

3. PTSD Causes Diagnosis Not completely understood Complex Mix of Factors
Stressful Experiences
Genetics
Temperament
Biochemical Regulation
Diagnosis
Physical Exam
Psychological Evaluation
DSM-5 Criteria
-Doctors do not have a definitive reason as to why some people get PTSD.
-PTSD is probably caused by a complex mix of factors including Stressful experiences, Inherited mental risks like a family history of anxiety and depression, temperament, and the way your brain regulates the hormones and chemicals your body releases in response to stress.
-A qualified healthcare professional looking at a patient with suspected PTSD will go through a few steps before making a final diagnosis including = performing a physical exam to make sure no other medical problems are causing the symptoms.
-They will perform a psychological evaluation discussing your signs and symptoms and the event or events that led up to them.
- Finally if certain criteria are met that are stated in the Diagnostic and Statistical Manual of Mental Disorders, also know as the DSM-5, a diagnosis will be made.

4. Mainstream Treatments
Psychotherapy
Cognitive Therapy
Exposure therapy
EMDR
Medications
Antidepressants
sertraline (Zoloft)
paroxetine (Paxil)
Anti-anxiety medications
prazosin (Minipress)
-Here are the mainstream treatments for PTSD, starting with psychotherapy.
-There are a few different types of psychotherapy that can be utilized.
Cognitve therapy is a type of talk therapy that helps you recognize the ways of thinking that are keeping you stuck.
Exposure therapy is a behavior therapy that helps you face both memories and situations that you find discomforting so you can learn to cope with them.
Eye movement desensitization and reprocessing also known as EMDR combines exposure therapy with a series of guided eye movements that helps you digest traumatic memories and change how you react to them.
Certain medications are prescribed and are potentially helpful for PTSD patients.
Antidepressants can help symptoms of depression and anxiety. They can potentially also help improve sleep problems and concentration. Selective serotonin reuptake inhibitors like Zoloft and Paxil are approved by the FDA for PTSD.
Certain anti-anxiety medications such as Xanax may be used.
Some studies have shown that Minipress may suppress or reduce nightmares in some people with PTSD, but a more recent study showed no benefit over a placebo.

5. Mainstream Treatments: Side Effects
sertraline (Zoloft)
Nausea (13-24%)
Headache (20-25%)
Insomina (12-28%)
Ejaculation Disorder (7-19%)
paroxetine (Paxil)
Nausea (15-24%)
Insomnia (11-24%)
Asthenia (10-15%)
Ejaculation Disorder (10-15%)
alprazolam (Xanax)
Memory Impairment
Addiction
Withdrawal
Pharmaceutical treatments for PTSD do work for some patients, but they may experience debilitating side effects. The real kicker is for the patients that are prescribed these medications and don’t experience any relief, but still experience the side effects.
Lets take a look at some of the side effects. The percentages listed are the incidence the side effects occurred in clinical trials.
As you can see Zoloft and Paxil have very similar side effect profiles with nausea, insomnia and sexual dysfunction being prevalent. Also, this is not discussed much but coming off of these antidepressants may require a taper as withdrawal symptoms can be experienced.
The anti-anxiety drug Xanax is dangerous when used chronically and heavily. Memory Impairment with possible blacking out is one of the more concerning side effects. And side effects aside, Xanax can be addictive with significant withdrawal symptoms in patients trying to discontinue after chronic, consistent use.
This point I am trying to make here is that we don’t see a high incidence of debilitating side effects in patients using cannabis as medicine. Most side effects of cannabis in low to moderate doses are fairly benign with no physical dependence. And you definitely don’t see sexual dysfunction with cannabis as medicine.

6. Endocannabinoid System
Found in all complex animals
Homeostasis
CB1 and CB2 receptors
Located all over body
Anandamide and 2-AG
Regulation of memories
Before we jump into cannabis I like to talk about the endocannabinoid system. Most healthcare professionals never learn a thing about the endocannabinoid system. And I didn’t even know it existed until after I graduated pharmacy school.
The endocannabinoid system is a complex regulatory system found in all vertabraes. It regulates diverse functions such as memory, digestion, motor function, immune response and inflammation, appetite, pain, blood pressure, bone growth, and the protection of neural tissues, among others.
It is responsible for maintaining homeostasis within the body, in other words maintaining a balance in the body.
There are more than 2 receptors involved, but the CB1 And CB2 receptors are the main receptors in the endocannabinoid system as shown in the picture.
These receptors are distributed through out the the body including the central nervous and immune systems and within many other tissues like the brain, GI system, reproductive and urinary tracts, spleen, endocrine system, heart, and circulatory system.
CB1 receptors are prevalent in the brain, but one part of the brain where there is a low density of CB1 receptors is the brain stem. This is the reason why cannabis does not cause respiratory depression like opioids, benzos and alcohol can.
Our bodies make two endocannabinoids on demand called anandamide and 2-ag.
The endocannabinoid system in relation to PTSD regulates the creation, consolidation, and extinguishing of traumatic emotional memories.

7. Endocannabinoid System: PTSD
The amygdala
Memory and Fear conditioning
Structural change
MRI Scans
Uncontrolled amygdala activation
Changes in ECS signaling
Lower anandamide
Abnormal CB1 receptor densities
Phytocannabinoids as treatment
In conjunction with psychotherapy
-The amydala is a small, almond-shaped part of the brain that’s associated with emotional memory and fear conditioning. It’s shown as the red dot there.
PTSD actually changes the structure and function of the amygdala. Functional MRI Brain scans show a hyperactive amygdala and hypoactivity of the hippocampus and prefrontal cortex in the brains of patients with PTSD compared to controls. The result of this imbalance is inadequate control of amygdala activation.
So there is a dense concentration of CB1 receptors in the fear network of the brain which includes the amydala, hippocampus and the prefrontal cortex. Patients with PTSD have changes in their endocannabinoid signaling system compared to healthy people and have lower anandamide levels and abnormal CB1 receptor densities.
When the human bodys endocannabinoid system is out of wack we can use phytocannabinoids like THC and CBD to restore a balance. With PTSD psychotherapy is very important and cannabis should not be used as the sole treatment in most cases.

8. PTSD: THC Direct on action CB1 and CB2 receptors Anxiety Reduction
Typically at “lower” doses
2.5mg or lower in new patients
Mood/Depression
Sleeping/Waking Nightmares
-delta 9 tetrahydrocannabiol also known as THC is the one cannabinoid most people are familiar with as its the one people typically look for when using cannabis for recreational purposes.
As we just talked about the the CB1 receptor on the last slide, THC has direct action on the CB1 receptor.
Looking beyond the high or euphoric effect, THC has many therapeutic uses, including some for PTSD.
THC can be helpful for anxiety caused by PTSD. This is kind of a double edged sword though as too much THC can possibly make the anxiety worse. So lower doses are typically better for treating anxiety and put I lower in quotations as a low dose for one person may be a massive dose for another. But for a brand new PTSD patient with no cannabis experience you shouldn’t start any higher than 2.5mg of THC.
When utilized correctly THC can provide relief from depressive symptoms caused by PTSD.
Sleep is probably one of the most underated aspects of health. If a patient cannot get adequate sleep mental health issues like PTSD can be exacerbated. THC is very useful for sleep and may help prevent waking nightmares caused by PTSD.

9. PTSD: CBD Indirect CB1/CB2 activator Studies with Rats Anxiety
THC buffer
2017 Review
Treatment for traumatic memories
Fear memory disruption
Adjunct to Psychotherapy
Has to be given after memory retrieval
Dose around Psychotherapy
CBD, short for cannabidiol, is the second most prevalent cannabinoid. And It doesn’t have any psychoactivity by it self.
CBD is an allosteric modulator which in other words means it indirectly activates the CB receptors. CBD has been shown to extinguish fear memories, facilitate disruption of contextual memories and reduce anxiety in rats and it is believed that biochemical/anatomical characteristics of models of fear memories and extinction in rats and humans are very similar.
CBD in a PTSD patient may also reduce anxiety and buffer THC’s possible adverse effects like acute anxiety, sedation and hunger.
A 2017 review of studies found evidence that supports CBD’s potential as treatment for lingering traumatic memories and their impacts.
Researchers found that CBD produces a reduction in learned fear expression when given in conjunction with fear memory reconsolidation or extinction by disrupting the former and facilitating the latter.
And for CBD to have this effect it has to given after memory retrieval as CBD had no effect if given without memory retrieval.
Given this knowledge CBD may prove useful as adjunct treatment to psychotherapy when traumatic memories are discussed.

10. Terpenes/Chemovar (Strain) Selection
Aromas and Physiological Effects
Stay away from pinene rich cannabis!
Memory enhancing
Limonene
Uplifting
Linalool and/or myrcene
Anxiolytic and analgesic
- Terpenes are the compounds in cannabis that give off the aroma, but also have physiological effects.
-Cannabis products that are dominant in the terpene pinene should avoided if possible.
-Alpha pinene may be anxiety-provoking, its memory-enhancing effects may make the extinguishing of aversive memories difficult.
-Its best to look for cannabis products rich in limonene, linalool and/or myrcene. For instance many of the purples or bubba kush related strains are typically rich in linalool and myrcene. Linalool and myrcene have anxiolytic and analgesic effects while limonene has an uplifting effect.
-Most cannabis products in Illinois will list the terpene concentrations through accessible lab reports or right on the packaging.

11. First PDI Visit Goals Drug Interactions
Improve Quality of Life
Drug Interactions
Assess Patients Cannabis Experience
No or little cannabis experience
Intermediate cannabis experience
Advanced Cannabis Experience
Product selection and initial strategy
Minimum Effective Dose
“Sweet Spot”
Follow Up
When a PTSD patient first comes into PDI ideally they will have a brief conversation with me or another pharmacist to devise a game plan. PDI is the only dispensary in Illinois to have a pharmacist available at most times.
The goals with PTSD patients usually involve anxiety reduction, improved sleep and mood and just ann overall better quality of life.
Initial Dosing Strategies with patients are typically based off the patients experience and comfort with cannabis.
Patients with no or little cannabis experience I will take a way different approach than someone with Advanced Cannabis Experience. Patients with no or little cannabis experience I typically recommend starting out with CBD Rich cannabis products or microdosing of a THC rich product. This conservative approach reduces the chances of any unwanted side effects and allows patients to find their cannabis sweet spot in a comfortable fashion.
A patient with intermediate cannabis experience can be defined as someone who is familiar with the effects of THC on their body and have somewhat of an idea how well they tolerate cannabis. Typically they are also able to share some of their previous cannabis experiences with clarity. I typically will recommend either a combination of CBD rich and thc rich products at low to moderate doses for these types of patients.
A patient with advanced cannabis experience can be defined as someone who has been self medicating for quite some time and knows exactly how well and the amount of cannabis they can tolerate. These patients are the easiest to dose since you don’t have to worry as much about adverse effects.
- Initial product selection and strategy is going to be based on the patients current cannabis use and any limitations, like if the patient cant inhale and so forth.
The idea is to get the patient to the minimum effective dose, also known as the sweet spot, which is the dose where they are getting sufficient relief without any adverse effects.
Following up is important because it may take multiple visits to find the best possible regimen.

12. Dosage Forms Inhalation Ingestible Sublingual/Buccal/Oromucosal
Combustion
Vaporization
Ingestible
Edibles
Oils (RSO)
Tablets/Capsules
Sublingual/Buccal/Oromucosal
Topical
Transdermal
We have quite a few dosage forms to work with in the state of Illinois to achieve this “sweet spot.”
Starting with inhalation we have a couple of different methods we can use. We have the old tried and true combustion method with either a pipe, joint, bong, or steamroller just name a few different ways. We prefer patients to inhale using vaporization over combustion to avoid any possible harmful by products. Every cannabis patient should have some sort of inhalation product unless they have some limitation that deters them from inhalation. The reasoning behind this is that inhalation is the fastest way to get the medicine into the body. You can think of inhalation as your rapid or break through cannabis medicine.
The downside to inhalation is that it wears off very quickly with relief really lasting only 1 to 3 hours. That’s were other dosage forms come into play like ingestible products as these products can last anywhere from 4-8 hours. But the downside is that there is a high variability as far as the onset of effect goes, anywhere from 30 minutes to 2 hours. I am a big proponent of rick simpson oil when it comes to getting CBD rich medicine into the body. I recommend patients to take at least one, maybe two doses of a CBD rich cannabis oil daily. RSOs are a good way to keep a constant baseline of cannabinoids in the body.
Sublingual forms like tinctures are excellent for new patients when we want to take a microdosing approach. Tinctures allow us to go drop by drop if need be in patients who are more comfortable with a conservative approach. RSOs can also be taking sublingually.
Topicals like creams and balms don’t really apply much to PTSD symptoms since they only work locally.
Transdermal dosage forms such as a patch are very convenient, but are by far the most expensive dosage form per dose.

13. Getting Your Cannabis Card
Formal Diagnosis of 1 of the 41 qualifying conditions
Completion of Physician Written Certification Form by Licensed Physician
Fingerprint/Background Check
Completion of Online Forms and Payment
Provisional Registration
Dispensary Transfer
-The actual process of getting a medical marijuana card in Illinois seems like an involved process, but its relatively simple especially with the help of PDI medicals staff or the with people at compassionate clinics
The first step is to determine whether you have a formal diagnosis of 1 of the 41 qualifying conditions like PTSD.
The next step and probably the most important step is to have a physician complete and sign a Physician written certification form. If your personal doctor wont sign, there is a list of Cannabis friendly doctors at pdimedical.com or compassionate clinics has cannabis educated physicians on staff.
The next step is to call PDI Medical and schedule an application appointment, which we do free of charge. Fingerprints and background checks are no longer required, but we will take your passport photo and we will also help you to make sure you have all the documents and paperwork the state requires. Finally, we will help you submit your application online. Sending a paper application is discouraged since the state implemented provisional registration earlier this month.
Provisional registration allows patients a temporary access card to a dispensary within 24 hours of application submission online that’s good for 90 days while they wait for the plastic hard card.
Some Illinois medical cannabis patients don’t realize this but you are allowed to change dispensaries once you get the plastic hard card. If youre interested in transferring to PDI you can give PDI a call and we can take care of the rest. Once you’re a PDI patient you can schedule appointments with myself or with anybody on our knowledgeable staff.

14. Resources
Backes, Michael, et al. Cannabis Pharmacy: the Practical Guide to Medical Marijuana. Black Dog & Leventhal Publishers, 2017.
J. L. C. Lee, L.J. Bertoglio, F.S.Guimaraes, and C.W. Stevenson (2017), “Cannabidiol Regulation of and Emotional Memory Processing: Relavance For Treating Anxiety-Related and Substance Abuse Disorders,” British Journal of Pharmacology, doi: /bph.13724
Paroxetine. Adverse Effects. Medscape Mobile App. WebMD, LLC.
“Post-Traumatic Stress Disorder (PTSD).” Mayo Clinic, Mayo Foundation for Medical Education and Research, 6 July 2018, treatment/drc
“Post-Traumatic Stress Disorder (PTSD).” Mayo Clinic, Mayo Foundation for Medical Education and Research, 6 July 2018,
Russo, Ethan B., and Jahan Marcu. “Cannabis Pharmacology: The Usual Suspects and a Few Promising Leads.” Cannabinoid Pharmacology Advances in Pharmacology, 2017, pp. 67–134., doi: /bs.apha
Salamie, Nicholas PharmD, RPh. “Alzheimer’s Disease and the Alternative to Opioids Act.” Powerpoint File.
Sertraline. Adverse Effects. Medscape Mobile App. WebMD, LLC.

15. Questions