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November 17, 2006

Is PTSD an anxiety syndrome best treated by cannabis?

Last Monday evening, Anderson Cooper 360, CNN's generally worthwhile evening news magazine, focused on the major stresses American military families must cope with: repeated deployments to Iraq, now becoming more common for both active duty and reserve personnel.

As an Army surgeon in Japan from September '63 to August '67, my first substantial experience with wounded GIs began roughly halfway through my tour in mid-November 1965 when forty or so wounded Ia Drang Valley survivors were delivered by helicopter to Zama Hospital on the outskirts of Tokyo just days after I'd become the Chief of Surgery. Zama had, until then, been the only Army Hospital in Japan; personnel for two others, the Seventh Field, and the 106th Evac, had just arrived, and they  soon became fully operational after hasty renovation of the two unused military barracks, also near Tokyo, that would house them. Planning for that dramatic medical expansion had begun with the decision to deploy  troops to Viet Nam earlier that summer following the Gulf of Tonkin incident.

Just as the nearly-legendary Battle of the Ia Drang Valley has come to be seen as a dress rehearsal for the vicious war that followed, so did the technique for air evacuaton of  wounded GIs to Japan that we pioneered in November 1965 become a model that would be improved and expanded until peaking after Tet in February '68 and then gradualliy tapering off as the war was gradually 'Viet Namized.' In fact, it had been the availability of the first version of the same medevac transport now shuttling GIs from Baghdad to Germany that had made it possible

 I rotated to Letterman in San Francisco as a chest surgery resident in August 1967 and found myself on the other end of the evacuation chain. I continued to care for GIs with complicated chest wounds until leaving the service in September '71. My exit, earlier than planned, was at least partiallly because I could no longer support a war I had once believed in.

CNN's presentation brought back a rush of memories; along with an appreciation of the many similarities and differences between the Viet Nam and Iraq wars; not only in terms of the quite different tactics employed and wounds produced, but also of the stresses they produced.  Along the way, there have been major changes in military culture resulting from the replacment of young conscripts by an 'all volunteer' Army with its greater emphasis on marriage and children.

When CNN segued into a consideration of PTSD, I  was quickly forced to acknowledge another major difference between the two wars; one that that certainly wouldn't be mentioned on TV: pot is still being used by thousands of Viet Nam veterans as their main treatment for PTSD. Sadly, thousands of others, many of them homeless, are still using alcohol for the same symptoms.  Many boomers, who were just discovering pot, even as  as Nixon was opting for a war against it, wound up in uniform: some tried it before they were drafted, others while 'in-country,' and still others after their return. It has been used by many of the vets I've interviewed; some, even as they have continued in support groups at the San Francisco VA, without ever mentioning their pot use to the psychiatrist.

In fact, my education at their hands is a good example of how Proposition 215 has worked to inform: patients who had been
self-medicating on their own, when pressed for details, were often able to educate me (often without realizing they were) to a clinical reality I wasn't aware of. Thus I  could place their use in the clinical perspective needed to characterize it in medical terms. That's the key difference between starting a clinical analysis with a nugget of hard fact (cannabis was successful treatment for years), as opposed to being kept in the dark by an enforced misconception (no drug of abuse can be useful or safe).

It has since become  easier to recognize  how often (non-specific) symptoms of anxiety are a part of PTSD; another fairly common examples have been the odd cases of sexual molestation I began hearing about when I started to take detailed family histories; not because I was looking  for them specifically, but perhaps because my questions about the details of school and childhood may have encouraged it. I have vivd memories of middle aged adults of both genders breaking into tears while telling me of events previously confided only to siblings or very close friends. Given the frequency of early divorce, remarriage, and custody battles in this population, sexual abuse at the hands of step relatives has not been that rare; and I am probably still not told of all that occurred. I soon also learned that often, an abused step-daughter is blamed by her own mother for provoking the abuse, if she were believed at all.

Beyond that, the tightening temporal proximity demonstrated by MCAs in their initiations of alcohol, tobacco, and pot suggest that the three agents still compete to become 'drugs of choice' for troubled adolescents. The inevitable conclusion is that young people who are successfully coerced into avoiding, or giving pot up, may become even more vulnerable to use of alcohol and tobacco as stress relievers. That certainly describes our modern Army; beyond that, its better pay, expanded benefits, and greater reliance on women soldiers, has increased the percentage married service members with young dependents. I can imagine no greater emotional pressure on families than the present cruel calculus of repetitive deployments of two young parents to dangerous duty.

Along with the much higher incidence of closed brain injury and lower limb amputation produced by IEDs, the civilian carnage from what is really an urban guerrilla war is already known to be producing an extraordinary incidence of PTSD among Iraq returnees. What I also know to be true, but could never be even hinted at in the CNN report, is that the PTSD care available to them through the military and VA would be not only less effective because cannabinoids could not be a choice, but those daring to use them might well risk all their benefits.

Doctor Tom

Posted by tjeffo at November 17, 2006 07:12 AM