Current Treatment Practices of Veterans Affairs

This paper critically examines specific and current treatment practices by America's Department of Veterans Affairs (VA). It shows the VA relies too heavily on addictive narcotics for pain relief, and on antidepressant medications that are often associated with serious adverse side effects. The VA's penchant for such treatments overlooks the rising efficacy of harm reduction practices in the battle against drug addiction. The paper maintains the VA would enhance harm reduction by allowing the therapeutic use of medical marijuana for veterans. Medical marijuana poses a safer and more effective alternative to the dangerous drugs prescribed by the VA. As such, Federal Law should be amended to allow the VA to prescribe medical marijuana for veterans suffering from specific physical and/or mental health conditions.

To appreciate the potential roles of medical marijuana in harm reduction, it is necessary to understand some basic facts about the drug and its current applications. Marijuana is a derivative of the Cannabis sativa plant (Turna, Patterson, & Van Ameringen, 2017). Despite long-standing prohibitions, it is the most commonly used illicit drug in the U.S., not to mention the world (Turna et al., 2017, pp. 1006-1007). Although cannabis is frequently used primarily for its relaxing and euphoric effects, humans have been harnessing its therapeutic properties for centuries and it is currently used to alleviate many physiological and psychiatric conditions (Turna et al., 2017). Hill (2015) explains that the active chemicals in medical marijuana are cannabinoids, which enhance or mimic the effects chemicals produced by the human body to optimize appetite, movement, pain relief, and other functions. Although there are dozens of cannabinoids, the two most important in health research and practice today are: (1) cannabidiol, which appears to have significant antianxiety and possibly antipsychotic effects; and (2) tetrahydrocannabinol (THC), which is responsible for marijuana's euphoric effects (but might have psychotic effects in some users). Medical marijuana consists of cannabidiol, THC, and other cannabinoids. Due to cannabidiol's tendency to moderate THC's psychoactive properties, marijuana's therapeutic effects depend on the ratio of cannabidiol to THC. Therefore, THC-cannabidiol ratios in different strains of marijuana have been engineered to obtain various desired therapeutic effects.

Hill (2015) further explains that depending on rapidly evolving state and local laws, Americans may now purchase medical marijuana in a variety of forms via authorized dispensaries, though not from traditional pharmacies because it remains illegal at the federal level. Patients also, legally or illicitly, grow cannabis for the treatment of many health conditions. Two U.S. Food & Drug Administration (FDA)-approved cannabinoids are also currently available in pill form: dronabinol and nabilone. Both are FDA-approved for appetite stimulation in wasting disorders and for treatment of nausea and vomiting associated with cancer chemotherapy.

Strong evidence currently supports the use of medical marijuana, especially in the treatment of chronic pain, neuropathic pain, and nausea (Turna et al, 2017). In the states permitting its use, medical marijuana is most commonly approved for treatment of conditions such as cancer, epilepsy, glaucoma, HIV/AIDS, multiple sclerosis, nausea, and severe and/or chronic pain (Hill, 2015; Turna et al, 2017). It should be noted that research on marijuana has long been funded and undertaken by groups supporting anti-pot agendas; therefore, it is unsurprising that literature on cannabis' efficacy as a medical treatment is somewhat inconsistent (Hill, 2015; Turna et al, 2017). Indeed, some inconsistencies are perhaps to be expected. For example, if a large number of people with anxiety use marijuana illicitly when conventional prescribed treatments fail, one would expect to see higher levels of anxiety among marijuana users due to the potential legal consequences. Seizing on this opportunity, anti-pot groups have been quick to cite these levels as evidence that marijuana causes anxiety (Hill, 2015; Turna et al, 2017). Despite the political and moral battle, facts show anxiety is a top-five medical symptom driving North American's cannabis usage (Turna et al, 2017)”even though as of 2015 no state had approved medical marijuana specifically for the treatment of anxiety (see Hill, 2015, pp. 2475-2477).

Turning back to the VA, one condition for which medical marijuana should be a major harm reduction force is post-traumatic stress disorder (PTSD). PTSD is as a trauma and stressor-related disorder. The Diagnostic and Statistical Manual of Mental Disorders (5th edition, DSM-5) stipulates its diagnosis is based on exposure to a precipitating traumatic event (criterion A) and then meeting criteria B (intrusive symptoms), C (avoidance), D (negative changes in cognition and/or mood), and E (adverse changes in arousal and reactivity) (Shishko et al., 2018). Shishko et al. (2018) report that, while the incidence of PTSD is alarmingly high within the general U.S. population, with a 12-month prevalence of 3.5 percent”the estimated incidence among veterans is almost seven times as high at 24 percent (pp. 86-87). Beyond the disabling impacts of PTSD itself, 80 percent of individuals also have comorbid psychiatric disorders with emotional, physical, and dissociative symptoms that further undermine essential functioning, employment, personal relationships, and even basic self-care.

In their analysis of published evidence pertaining to the use of cannabis and cannabis derivatives by veterans with PTSD, Betthauser, Pilz, and Vollmer (2015) explain that, when inhaled, delivered orally or via the skin, cannabinoid receptors activate to modulate the release of neurotransmitters. This release produces many central nervous system effects such as pleasure enhancement and changes to our memory processes. These positive physiological effects support the rationale for using cannabinoids to treat three core PTSD symptoms: re-experiencing, emotional numbing and avoidance, and hyper-arousal.

Betthauser et al. (2015) describe studies which reveal direct correlations between severe PTSD symptoms and increased motivation to use cannabis in coping”particularly among patients with poor stress tolerance and/or troubling emotional ranges. High-quality research is limited, but analysts found four studies whose data link veterans' cannabinoid use to the reduction of specific PTSD symptoms such as nightmares and insomnia. However, more well-designed controlled trials are clearly needed to further explore cannabinoids as a complementary or alternative option to today's conventional treatment for PTSD in veterans. Betthauser et al. conclude the existing evidence shows that significant numbers of veterans with PTSD currently rely on cannabis and/or cannabis derivatives to control their PTSD symptoms. Also, many of these users report benefits such as reduced anxiety, reduced insomnia, and enhanced coping abilities.

Medical marijuana could also help the VA reduce the harm associated with antidepressants. Turna et al. (2017) explain that anxiety-related disorders are the most common mental health conditions observed in veterans and the general U.S. population. In the U.S. the primary pharmacological treatment for anxiety disorders and many of their comorbidities are antidepressants. However, despite massive investments in these drugs, treatment response rates to standard antidepressants remain so poor that between 40 and 60 percent of patients receiving them continue to have residual/impairing symptoms. Worse, the antidepressants are linked to major, often disabling side effects which lead to high levels of noncompliance, discontinuation, and seeking alternative treatments.

Furthermore, Burgess et al. (2016) describe troubling complications related to the VA's reliance on opioids in pain treatment. On one hand, there are concerns, despite evidence that African-American veterans and other patients often experience more severe and disabling chronic pain than whites, African-American patients are less likely to be prescribed opioids. These findings have understandably raised concerns about under-treatment of pain in African-Americans. At the same time; however, America's current and devastating public health crisis of opioid addiction raises alarm bells about the possible effects of efforts to correct racial disparities in pain treatment. If doctors were to continue to choose opioids to address pain under-treatment in blacks, even greater harm may result as more Americans are subjected to addictive and often lethal treatments.

Worse still, there are serious reasons to doubt that increased prescriptions of opioids for African-Americans would actually reduce pain under-treatment. In a study involving veterans, Burgess et al. (2016) analyzed whether pain-related outcomes vary by race among veterans with a diagnosis of chronic non-cancer pain and whether opioid use could improve any observed racial disparities. The study showed, regardless of race, receipt of an opioid prescription was not associated with perceived treatment effectiveness for most patients but was associated with greater pain interference. In other words, the opioids failed to improve treatment outcomes and contributed to higher incidences of pain that interferes with or limits one's regular physical, mental, and social activities. Burgess and colleagues conclude that their findings "raise questions about the benefits of opioids for musculoskeletal pain and point to the need for alternative treatments for addressing chronic noncancer pain" (p. 13). By 2015, at least 19 states specifically approved medical marijuana for the treatment of serious pain (Hill, 2015).

There are multiple potential applications for medical marijuana in the application of much-needed harm reduction practices at the VA. An important element of such harm reduction would be to minimize the adverse effects of treatment stoppage. Although the research is rather inconsistent, it seems likely that, as with all drugs, long-term use of marijuana even for therapeutic purposes would result in harmful effects at least for some individuals (Irons et al., 2014). Care must be taken to ensure safe and healthy discontinuation once the therapy is no longer needed. Fortunately, evidence indicates that discontinuation of medical marijuana would be decidedly less complicated than is the case with the highly addictive and harmful opiates and other treatments the VA currently prescribes. A study of 84 cannabis dependent veterans by Irons et al. (2104) suggests that even individuals with marijuana use problems could achieve successful cessation through timely quit efforts that include fairly intense exercise. The subjects were veterans who volunteered to participate in self-guided cessation. The results indicate that participants who engaged in moderate to high levels of physical activity were significantly less likely than those reporting low activity levels to report a cannabis lapse during the week following a quit attempt. By contrast, participants with low levels of physical activity were likely to report greater average use of cannabis in the first four days of the cessation period. Therefore, veterans treated with medical marijuana should be able to stop using more easily than those using many of the VA's current, often highly addictive and dangerous treatments.

America's veterans have put their welfares and lives on the line to defend and promote our freedoms and nation's interests. The nation dishonors their valiant and selfless service by failing to address even their most basic needs. The VA currently relies heavily on treatments that are linked to harmful side-effects and are ineffective, addictive, and even life-threatening. America's veterans clearly deserve better. Fortunately, the steadily evolving research indicates that medical marijuana could be an important step in promoting harm reduction and a long overdue step by the VA. Medical marijuana could be used to safely enhance treatment for various conditions affecting veterans”with lower risks of side effects and cessation problems compared with many current VA treatments. Federal Law must be amended to grant the VA the latitude to prescribe medical marijuana, where appropriate, for veterans with diverse physical and mental health issues. At the very least, this shift in policy would reduce harms resulting from the VA's current treatment practices.

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