—the new medical cannabis-focused publication brought to you by the publishers of 

®. In the few short years that I’ve been entrenched in the cannabis industry one thing has become abundantly clear to me: Patients are finding relief with medical cannabis and passionately driving the science forward. The goal of this new publication is to help educate the key players in medical cannabis: patients, doctors, nurses, pharmacists, caregivers, researchers, and advocates. We plan to highlight a specific disease or condition in each issue for which medical cannabis has been shown to be an effective treatment by sharing patient stories, research updates, and perspectives from the medical community.

The focus of this first edition is post-traumatic stress disorder (PTSD) in veterans and how medical cannabis is being used and studied as a treatment option. In a fortuitous turn of events, I was introduced to Ann Brum of Joint Venture & Co. by a mutual friend toward the end of 2019. Ann passionately shared the work she had been doing with Dr. Marion McNabb of the Cannabis Center of Excellence and Stephen Mandile, a veteran and advocate, to conduct an anonymous study of veterans using cannabis. Their team also hosted a series of local community education events in Massachusetts called the Cannabis Advancement Series. The passion and earnest desire to help the veteran community is clear to anyone who knows Ann, Dr. McNabb, or Stephen, and we are honored and excited to share the work they’ve been doing in this edition along with some of their personal stories. This project has been a true collaboration and I want to thank them tremendously for their time, expertise, and insight.

Our first article in this issue, written by Dr. McNabb, discusses the data from her 2019 Veterans Health and Medical Cannabis Study, which was conducted in partnership with the University of Massachusetts (UMass) Dartmouth. Next, we learn about Stephen’s personal journey to medical cannabis as a treatment for his PTSD and chronic pain after suffering a spinal cord injury during his service in Operation Iraqi Freedom. His story is truly inspiring!

On the medical side, Dr. Staci Gruber, the Director of Marijuana Investigations for Neuroscientific Discovery (MIND) at McLean Hospital, shared her interest in medical cannabis. Dr. Gruber and her team at MIND are conducting fascinating research in medical cannabis focusing on veterans and other areas.
In another article, Tracey Gregory, RN, shares her unique perspective as a hospice nurse working with veterans and how she has seen medical cannabis offer them comfort and relief.

Rounding out this special first edition are the stories of a Veteran Affairs (VA) caregiver—Jamie Pascua—offering support to her veteran husband and that of two advocates—Ann Brum and Wayne Smith—whose passion for educating their communities and changing legislation for veterans to have access to cannabis is beyond impressive.

 gets tossed around a lot, but I think it’s important to understand that there is real meaning behind it and a focus on the individual patient. The people that use medical cannabis have amazing stories to share and those stories are shaping the future of access for the patients that come after them. Veterans hold a special place in our society as those who are willing to sacrifice themselves for the greater good and protection of our country. It’s imperative that we offer them the best options for their care—whatever that may be. I am honored to present this special first edition of 

 focused on veterans. I hope everyone reading this takes away something special from the veterans, researchers, advocates, and medical professionals that are working so hard to make a difference in this community—I know I certainly have and I thank each of them for sharing their stories and work with us.


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Articles

From the Editor

Welcome to the first edition of Cannabis Patient Care!

Cannabis Patient Care: Cannabis Medicine Personalized

Dr. Marion McNabb and colleagues report on the findings from the anonymous 2019 Veterans Health and Medical Cannabis Study, which was a national and Massachusetts-focused research study led by McNabb, Stephen Mandile, leading Iraqi War Veteran and medical cannabis advocate, and Dr. Stephen White, Professor at UMass Dartmouth. The study’s main objective was to collect anonymous, self-reported data from US military veterans regarding their current health conditions, conventional medical treatments, medical cannabis use, and its effectiveness with self-reported health conditions and symptoms, and issues related to access and stigma.

As of 2020, there are more than 18 million veterans in the United States, with over nine million veterans who access healthcare each year provided by the Department of Veterans Affairs (VA)(1). Every year, more than 200,000 veterans transition out of service (2).

US military service members and veterans often face particular and comorbid health issues more than their civilian counterparts because they are at risk for different injuries during their service. These could be combat or stress related, and many injuries are life-threatening or can cause long-term disability. Additionally, service members are also at higher risk for health problems related to exposure to environmental hazards such as contaminated water, chemicals, infections, and burn pits. Service members are also disproportionally at risk of developing a variety of mental health problems, including anxiety, post-traumatic stress disorder (PTSD), depression, substance use disorder (SUD), and suicide (3).

Research points to the early transition period for veterans as a critical time to support them with the readjustment period and its associated challenges (2). Vogt and colleagues conducted a five-year study with a nationally representative sample of more than 9500 US veterans during their first year after military service. The study assessed veterans’ well-being over time related to health, work, and social relationships over three intervals. The study, published in March 2020, found that health concerns were the top issues, with 53% of veterans reporting chronic physical pain and 33% reporting chronic mental health conditions. The top conditions reported included: chronic pain, sleep problems, anxiety, and depression (4).

Veterans reported overall that they were less satisfied with their health than either their work or social relationships after returning home (4). Zone deployed veterans reported more health concerns, and women reported more mental health concerns compared to their nondeployed and male peers (5).

The VA reports that veterans suffer from chronic pain, with around 60% of veterans returning from combat, and 50% of elder veterans reporting suffering from chronic pain.Nationally, 30% of Americans suffer from chronic pain (6).

The resulting and compounding health conditions that veterans face post-deployment comes with the need for healthcare, numerous prescription medications, and mental health interventions.

Nguyen and colleagues published a study in 2017 that looked into the prevalence of medication dispensing across VA and non-VA care providers among a group of veterans. The study included a cohort of more than 52,000 veterans and found that on average they were prescribed 40 medications per year, and 17.4% of them had medication use from non-VA sources, including antibiotics, antineoplastics, and anticoagulants. The non-VA and VA medication sources were not in the same health records, causing fragmented care and documentation of medications (7).

Another survey conducted in 2020 of 1700 US Iraq and Afghanistan veterans found that 46% were prescribed anti-depressants, 35% anti-anxiety medications, 36% sleeping pills, and 32% opioids (8). An additional study led by the Defense Department found that nearly one in four active-duty members had at least one prescription for an opioid at some point in 2017. The study also noted that about one in four veterans had at least one opioid prescription, yet only one tenth of a percent (0.001%) of veterans were receiving care for a diagnosed opioid use disorder (9).

Based on our research and findings in the studies described above, we set out to conduct our own study in 2019 to discover how medical cannabis was helping veterans in Massachusetts and nationally. The study’s main objective was to collect anonymous, self-reported data from US military veterans regarding their current health conditions, conventional medical treatments, medical cannabis use, and its effectiveness with self-reported health conditions and symptoms, and issues related to access and stigma. Here we report on some of our findings from that study.

Before we delve into our own data, we’d like to provide some additional context for the various ailments facing veterans. Specifically, high addiction rates and PTSD are more common in veterans than the general public. Let’s take a closer look at those two conditions, the available treatments, and the ways in which cannabis has been effective.

Military deployment is associated with smoking, unhealthy drinking, illicit drug use, and risky behaviors. There is a zero-tolerance policy for veterans that mandates random drug testing and often discourages veterans from seeking help. Service members can be dishonorably discharged and face criminal prosecution for a positive drug test.

According to the US National Institutes of Drug Abuse (NIDA) more than 1 in 10 veterans have been diagnosed with a substance use disorder (SUD), which is slightly higher than the general population. Veterans are also impacted by issues related to substance abuse, including pain, suicide risk, trauma, and homelessness (10).

In terms of substances, cannabis is the vast majority of illicit drug use among veterans. Historically, the VA has not recognized medical cannabis, and thus has recorded cannabis positive drug tests as cannabis use disorder (CUD). From 2002–2009, CUDs increased more than 50% among veterans treated at the VA (10).

Opioid and other prescription drug misuse is a major issue with the veteran community, post deployment. From 2001–2009 military physicians wrote nearly 3.8 million prescriptions of pain medications, with the percent of veterans in the VA who received an opioid prescription increasing from 17–24%, quadrupling the amount from 2001 (10). The opioid overdose rates of veterans increased from 14% in 2010 to 21% in 2016 (10).

More recently, self-reported use of prescriptions for pain have decreased. From 2011-2015 the percent of reported use of pain medications decreased by nearly half (10).

Among veterans who present for the first time for care with the VA, nearly 11% meet the criteria for an SUD. It is reported that about 20% of high-risk behavior deaths among veterans were attributed to alcohol or drug overdose (10).

Additionally, veterans who have an SUD also may have comorbid conditions such as PTSD, depression, and anxiety. In fact, veterans with SUDs are 3–4 times more likely to be diagnosed with PTSD or depression (10). Among recent Afghanistan and Iraq veterans, NIDA reports that 63% of those who were diagnosed with having an SUD met the criteria for PTSD (10).

Veterans also face disproportionate rates of suicide compared to their civilian counterparts. In fact, in 2017, 16.8 veterans committed suicide per day and the suicide rate for veterans was 1.5 times the rate for non-veteran adults (1). In 2017, a VA-funded study of nearly 124,000 veterans found that those who received the highest doses of opioids were twice as likely to die of suicide than those receiving the lowest doses (10).

According to the American Psychiatric Association (APA), PTSD is a “psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event such as a natural disaster, a serious accident, a terrorist act, war/combat, or rape or who have been threatened with death, sexual violence or serious injury.” PTSD can affect any person, any nationality, culture, or at any age. People with PTSD face disturbing thoughts and feelings related to their traumatic experience that can last a long time after the event. Events are relived through flashbacks, nightmares, and they may also feel sadness, fear, anger, or detached from other people. People with PTSD often avoid situations that remind them of the traumatic event and may have strong negative reactions to something as ordinary as an accidental touch or loud noise (11).

Several PTSD scales are commonly used to diagnose PTSD severity, including the PTSD checklist called the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) Post-traumatic Stress Disorder Checklist (PCL-5), which is a self-reported questionnaire required by the VA for veterans being treated for PSTD (12).

PTSD prevalence among veterans varies greatly by wars and eras. According to a study conducted by Reisman and colleagues of Iraq and Afghanistan veterans, 13.5% of deployed and nondeployed veterans screened positive for PTSD whereas other studies showed rates as high as 20% and 30% (12).

According to the national Veterans’ Affairs, the number of veterans who suffer from PTSD varies by service era:

Between 11–20% for those who served in Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF)

12% of those who served in the Gulf War (Desert Storm)

30% for those who served in the Vietnam War have had PTSD in their lifetime

Another cause of PTSD in the military can be military sexual trauma (MST). According to the VA, 23% of women reported sexual assault when in the military, and 55% of women reported experiencing sexual harassment when in the military. Also, 38% of men report having experienced sexual harassment while in the military (13).

PTSD often has associated comorbidities, with depression being the most common. Data reported by Reisman and colleagues in a review of what’s working for treatment of PTSD in veterans showed that major depressive disorder is nearly three to five times more likely to emerge in those with PTSD than not. Physical pain is also associated with PTSD. Veterans returning from Iraq and Afghanistan report chronic pain to be one of the most common symptoms, with 15–35% of patients with chronic pain reporting to also have PTSD (12).

Additionally, anxiety and substance abuse or dependence is also common among those who suffer from PTSD. The VA reports that more than 2 out of 10 veterans with PTSD also have an SUD, and almost 1 out of every 3 veterans seeking treatment for an SUD also has PTSD (13).

Psychological interventions are the first line of treatment for PTSD among veterans, cognitive processing therapy (CPT) and prolonged exposure (PE) therapy are the most common approaches (12). Eye-movement desensitization and reprocessing (EMDR) is also recommended as an effective first-line treatment. Pharmacological interventions are common as a second- or first-line treatment approach. Antidepressant medications called selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are the preferred class of medications, and studies show only 20–30% of patients achieve complete remission with using an anti-depressant (12).

There are currently four antidepressants that are recommended by the VA for those who suffer with PTSD: Sertraline (Zoloft), Paroxetine (Paxil), Fluoxetine (Prozac), and Venlafaxine (Effexor) (14). SSRIs have side effects including insomnia, drowsiness, nausea, dizziness, nervousness, agitation, dry mouth, headache, blurred vision, and sexual problems (15). The VA has a treatment decision aid application to help veterans find the right therapy or medication for managing their PTSD symptoms (16).

The economic consequences of having PTSD are high for veterans. The first-year treatment for Iraq and Afghanistan veterans treated through the VA is estimated to be $8300 per person. The healthcare costs, overall, are 3.5 times higher for veterans with PTSD than those without the disorder (12).

The use of medical cannabis to treat symptoms of PTSD has emerged as a possible alternative therapy, however, the evidence related to treatment efficacy is conflicting. A recent comprehensive literature review published in 2017 by Klimkiewicz and Jasinska looked at more than 10,000 peer-reviewed publications and reported that there is still a need for conclusive research related to the impact of cannabis for those who suffer with PTSD. The review noted that cannabis use does not appear to increase the likelihood of developing depression, anxiety, and PTSD (17).

As of 2018, 16 states had approved the use of medical cannabis for those who suffer with PTSD (18). However, there is currently a lack of population level data and controlled studies of cannabis use and PTSD in the US. Additionally, studies are reporting conflicting data as to the clinical benefits of medical cannabis for those with PTSD, and specifically veterans who have PTSD.

In 2015, Betthauser and colleagues conducted a literature review of the use of cannabis for PTSD among veterans. The search found 11 research studies pertaining to cannabis use by veterans who suffered from PTSD. Some studies reported a direct correlation between more severe PTSD symptomatology and increased motivation to use cannabis for coping purposes. Data from four small studies suggested that cannabinoid use was associated with global improvements in PTSD symptoms or amelioration of specific PTSD symptoms such as insomnia and nightmares (19).

One study by Jetly in 2015 found a significant positive effect of cannabis in reducing PTSD-associated nightmares (20). In addition, cannabis use as motivation to improve sleep in PTSD patients seems to be strongly correlated (21).

In 2018, Shishko and colleagues published a systematic literature review to understand the use of cannabis among those suffering with PTSD. The review found five studies that evaluated the use of cannabis for PTSD. Three studies were found to have a benefit, and two studies were found to have a statistically significant difference in worse PTSD outcomes (18).

However, more recently, in 2019 researchers Lake and colleagues in Canada conducted an analysis of health survey data from more than 24,000 Canadians and concluded that people who have PTSD but do not medicate with cannabis are far more likely to suffer from severe depression and have suicidal thoughts more so than those who reported cannabis use over the past year (22). The authors noted that their study was the first nationally representative survey to show promising benefits of treating PTSD with cannabis and reducing severe depression and suicidal states. They reported that with such limited options for treating PTSD, many have taken to medicating with cannabis (22).

Other researchers in a US Department of Defense funded study found that cannabis use may increase suicidality in military personnel with elevated PTSD symptoms. In a study of 545 veterans in a one-year study, they found that cannabis use and PTSD symptoms increased suicidal behavior over an 11-month period (23).

O’Neil and colleagues in 2017 published a systematic literature review to understand the benefits and the harms of cannabis for PTSD. They found two systematic reviews and three observational studies that were deemed to have a high risk of bias, but noted there are several ongoing research studies to look at the efficacy (24).

LaFrance and colleagues analyzed data from 400 Strainprint (cannabis journaling mobile application) users and found the sustained reduction of symptoms of PTSD among cannabis consumers who self-reported PTSD diagnosis (25).

Cannabis research in the US is very difficult to conduct because cannabis is still federally illegal. This limits researchers and academic institutions that receive federal grants or funding from participating. To conduct a clinical trial with cannabis in the US, researchers must use cannabis from only one approved source—the University of Mississippi. Often the cannabis produced from that source is not representative of the cannabis available widely on the market (17).

To date, there has only been one clinical trial completed in 2019 to evaluate the use of cannabis as a treatment for PTSD symptoms. The leading researcher, Dr. Sue Sisley of the Scottsdale Research Institute and the Multidisciplinary Association for Psychedelic Studies (MAPS), worked for 10 years from the start of the research design, through regulatory approval, and conducting the study. The results are being analyzed currently for publication (26).

Veterans Support for Medical Cannabis and Research

Despite the conflicting research findings, veterans are continuing to advocate for the use of medical cannabis as an alternative to the often-deadly cocktails of prescription medications and opioids they are currently prescribed.

In 2017, an American Legion study found that 92% of veterans supported research into medical cannabis and 82% reported wanting to have cannabis as a federally legal treatment. Eighty-three percent (83%) of veterans reported that the federal government should legalize cannabis (27). The American Legion has called for the VA to invest in research for cannabis to be an alternative treatment for PTSD (27).

Since 2018, the Disabled American Veterans (DAV) have included public pushes for medical cannabis use and research for veterans (28). Specifically, the DAV called for research into cannabis as an alternative pain relief option for those who suffer from PTSD, pain, and traumatic brain injuries (TBI) (28).

Iraq and Afghanistan Veterans of America’s (IAVAs) most recent national survey showed that one in five members use medical cannabis. However, fewer than one third of veterans mentioned cannabis use to their VA doctor because of fear of loss of jobs or reprisal from the VA (29).

The anonymous 2019 Veterans Health and Medical Cannabis Study was a national and Massachusetts-focused research study led by Dr. Marion McNabb, CEO of Cannabis Community Care and Research Network (C3RN), Stephen Mandile, leading Iraqi War Veteran and medical cannabis advocate, and Dr. Stephen White, Professor at the University of Massachusetts (UMass) Dartmouth. The study’s main objective was to collect anonymous, self-reported data from US veterans regarding their current health conditions, conventional medical treatments, medical cannabis use and its effectiveness with self-reported health conditions and symptoms, and issues related to access and stigma.

The research study utilized a 100+ question anonymous survey online and recruited US veterans to take the survey using a convenience sampling approach. The online survey was developed by Cannabis Community Care and Research Network, UMass Dartmouth, and Mandile. The survey questions were developed using standard scales found in the literature, with input from Dr. Staci Gruber from McLean Hospital and Harvard Medical School.

The study instrument was approved by the UMass Dartmouth Charlton College of Business Institutional Review Board. The survey was powered by SurveyMonkey and participants were recruited through study partners. Study partners were provided their own unique links to share the survey through their respective social and email listservs. Press releases of data were sent to the local media for TV and print publication, promoting preliminary findings to drive policy change.

In addition to the research study, the team launched the Cannabis Advancement Series (CAS) together with Joint Venture and Co., leading six community education events in Massachusetts regarding veterans’ access and highlighting the need for alternatives. Data from the study was reported at each of the events to promote community awareness and change for veterans in Massachusetts. Please refer to 

 for the events and speakers who advocated in 2019 for veterans access. Nine primary study partners were recruited to support sharing and funding the study, however the study had more than 39 supporters.

Data collection lasted from March 3 through December 31, 2019, and a total of 565 US veterans completed the survey, of which 201 (36%) were from Massachusetts. Veterans reported from 48 states, including Puerto Rico and the District of Columbia.

Among all veterans who responded, 30% were rated as 100% disabled by the VA (the average disability rating is 56%), and 83% of total respondents were male. More than 50% of those who responded were above the age of 50, and 79% identified as white.

Of those who responded, 31% served in the War in Iraq (Operation Iraqi Freedom), 24% did not serve in a war, 21% served in the Vietnam War, 18% served in the Persian Gulf War, 14% selected “Other war,” 13% served in the War in Afghanistan, and 8% served in Operation New Dawn. Please see 

In terms of the branch of service, 50% of respondents were in the Army, 21% were in the Navy, 17% were in the Air Force, and 16% were in the Marines. Veterans reported being exposed to several toxins during deployment, with 33% exposed to burn pits, 25% asbestos, and 12% Agent Orange.

According to the VA Combat Exposure Scale, 52% of veterans reported moderate to heavy combat exposure, and 30% reported being homeless currently or in the past.

In terms of health conditions veterans were facing in our sample, 38% reported chronic pain as the top health condition, followed by 25% PTSD, and 9% anxiety.

Nationally, veterans reported using on average 4.1 medications a day to manage their conditions and spent $98.40 a month out of pocket for prescription or over the counter medications. Only 16% of veterans in our sample reported not having any kind of health insurance. Nationally, 30% of respondents reported having over the counter or prescription medications at their home that they do not use and need to get rid of. In addition, 56% reported getting their prescriptions mailed to them from the VA, and only 5% reported being diagnosed for an opioid use disorder in the past, with 1% currently diagnosed.

Among the symptoms veterans reported having, 68% reported depression, 68% sleep problems, 64% pain, 57% anxiety, and 37% attention deficit disorder.

In terms of cannabis use, 92% reported consuming medical cannabis, and 72% of veterans have consumed cannabis for 13 months to more than 10 years.

Among those who reported medical cannabis use, the top conditions they reported it being the most helpful for included: 37% chronic pain, 25% PTSD, 11% anxiety, and 7% depression.

Veterans were asked to identify all health conditions (in addition to the top condition) that they found cannabis helpful for. Overall, 70% reported it useful for pain, 64% anxiety, 57% depression, 53% PTSD, and 37% insomnia. Please see

In terms of side effects of medical cannabis use, 68% reported dry mouth, 35% increase energy, and 35% changes in appetite.

Nationally, 78% of veterans reported actively trying to reduce the use of unwanted over the counter or prescription medications with medical cannabis. See

Among those who reported PTSD as their top condition, 75% scored a PTSD positive score when completing the DSM-5 (PCL-5) checklist that the VA uses to clinically diagnose PTSD. A total score of 50 is considered to be PTSD positive in the military, and veterans in our sample had an average score of 59. In our national sample, 25% of veterans reported PTSD as their top condition (n = 144) for which cannabis was most helpful.

In our study, 144 veterans nationally identified PTSD as their top condition (n = 144) for which medical cannabis is helpful. Nationally, veterans reported spending an average dollars per week (N = 565) of $85.77 or $343.08/month on medical cannabis. This average was slightly lower than those who reported PTSD, who report spending $91.99/week or $367.96/month. Veterans with PTSD (N = 144) report spending $85 a month on prescriptions compared to our national veterans’ sample (N = 565), who report spending $98 a month on prescriptions.

Among veterans with PTSD in our national sample, 35% report reducing antidepressants with the use of medical cannabis, compared to 26% of the national sample reporting reducing antidepressant use with cannabis. Additionally, among those with PTSD, 11% of respondents report reducing opioid use with cannabis, compared to 17% of the overall national sample reducing opioid use with medical cannabis.

For veterans with PTSD, 68% (n = 91) report using alcohol much less with the use of cannabis, 19% less, and 12% report about the same. In terms of quality of life, veterans with PTSD report 66% greater daily quality of life much more, and 31% more. In addition, 78% report using opioids much less now, and 43% reported using prior non-opioid medications much less now, 29% less now, and 28% about the same. Among those with PTSD, 50% reported smoking tobacco much less now, 29% about the same amount of use, and 17% less now.

Among veterans with PTSD, 94% reported cannabis helps them experience psychological symptoms (anxiety, stress, sadness) much less or less now. Additionally, 96% of veterans with PTSD report they experience a greater or much greater quality of life due to their cannabis use.

In terms of barriers to accessing medical cannabis among veterans in our national sample who have PTSD (n = 144), the largest barriers include (note that veterans could select all that apply): 57% money to purchase products; 46% access the right products; 36% stigma; 33% owning a firearm; 33% money to get a medical card; 28% workplace testing; 27% place to consume cannabis; 16% lack of knowledge; and 5% previous bad experience.

In terms of VA provider and policy related to medical cannabis use, as of VHA directive 1315 issued on December 8, 2017, it is VA policy that VHA providers and pharmacists should discuss cannabis use with veterans as it is relevant to their clinical care. They are however prohibited from being state-licensed cannabis providers, but still encouraged to discuss with their patients how cannabis can be used for their clinical care, including possible interactions with the medications they are taking and this information must be recorded.

In our sample, we found that the majority of veterans have reported medical cannabis use to their VHA provider, but 63% do not know if they support it.

With the VA mandating that the providers should discuss cannabis use with veterans, we found in our sample that this dialogue is not happening. Generally, veterans report finding out medical cannabis information from other informal, non-clinical sources, yet the majority of veterans in our sample (78%) report using cannabis currently or in the past as an alternative to other medications.

Research Focus

A report on the findings from the anonymous 2019 Veterans Health and Medical Cannabis Study, which was a national and Massachusetts-focused research study led by Dr. Marion McNabb, Stephen Mandile, and Dr. Stephen White.

The 2019 Veterans Health and Medical Cannabis Study

Stephen Mandile—veteran, cannabis patient, and advocate—shares his personal experience with medical cannabis and how it has given him a new mission to help other veterans gain access to this plant.

Post-traumatic stress disorder (PTSD) is defined by the Mayo Clinic (1) as a mental health condition triggered by experiencing or witnessing a terrifying or life-threatening event. Symptoms can range from flashbacks and nightmares to severe anxiety and uncontrollable thoughts about the event. The Mayo Clinic states (1) that “PTSD symptoms are generally grouped into four types: intrusive memories, avoidance, negative changes in thinking and mood, and changes in physical and emotional reactions. Symptoms can vary over time or vary from person to person.” According to the American Psychiatric Association (2), PTSD affects approximately 3.5% of US adults every year, with an estimated one in 11 people being diagnosed with it in their lifetime.

Despite the high occurrence of PTSD in the general population, veterans of warfare are still more likely to experience symptoms of PTSD. The US Department of Veterans Affairs (VA) has a National Center for PTSD designed to lead research and assist veterans that are experiencing symptoms (3). The VA states that the percentage of veterans who experience PTSD varies depending on the service era. For example, according to the VA 11–20% of veterans that served in Operations Iraqi Freedom and Enduring Freedom are diagnosed with PTSD every year whereas 30% of veterans that served in Vietnam are estimated to have experienced PTSD at some point in their lifetimes (4).

While it is clear that PTSD is a problem for many veterans, there has been little change in treatment and medication for far too long. The typical medications prescribed for PTSD include antidepressants such as Zoloft, Paxil, Prozac, and Effexor. Studies have also shown that PTSD plays a role in veteran suicide (5), which according to the 

2019 National Veteran Suicide Prevention Annual Report

 was as high as 17 (~16.8) veterans per day in 2017 (6). 

When faced with PTSD, many veterans turn to their local VA for help. Stephen Mandile, a veteran of Operation Iraqi Freedom and veterans’ advocate, was faced with this challenge upon returning home from Iraq by medivac. Here, he shares his story to find alternative treatment with medicinal cannabis and how that led him down a road of advocacy work to help other veterans.

After suffering a spinal cord injury in Iraq, Mandile was sent back to the US by medivac and subsequently tested for PTSD. “I was having problems with aggression, alertness, depression, anxiety, and just being able to slow down,” said Mandile. “Everything felt like it was going 100 miles per hour.”

He tried a number of different medications to ease his pain and other symptoms. Ultimately, Mandile tried 57 different medications to give him relief from his PTSD and chronic pain but the effects made him feel numb to everything. Finally, Mandile’s wife gave him an ultimatum to get off of the medications that were not helping. She suggested that he try medical cannabis, which was shocking to Mandile at first because of his own bias towards cannabis as a drug of abuse.

“At first my reaction was that ‘I’m not I’m not going to become a druggie.’ I’m taking the medicines that my doctors are telling me are good and safe for me,” said Mandile. “Why would I ever take cannabis? But her suggestion planted a seed to get me looking into the medications I had been taking such as fentanyl, oxycodone, Xanax, and Klonopin.”

After doing some research, Mandile decided that the opioids and benzodiazepines he was taking were not right for him and decided to give medical cannabis a try. His first experience with cannabis was not perfect, but it did open his eyes to new feelings. He explained that an hour after he tried cannabis, they had to take his 6-month-old daughter to the emergency room and that made him feel very paranoid.

“At the same time though, I was glad to be feeling anything at all because when I was on the other medications, I was just numb and I didn’t care,” said Mandile. “So just being aware of my current state was something kind of shocking to me, like even the fact that I could feel paranoid was something I hadn’t felt in 10 years.”

Mandile also described how things started to feel more slowed down for him—a change from that 100-mile-per-hour feeling he mentioned earlier. He went from having no fuse and feeling like his anger went from zero to 100 in a second to having a few moments to catch himself and practice mindfulness. “Cannabis has allowed me to not think that the sky is falling because something happened,” said Mandile. “Another way I try to explain it is that without cannabis I feel like I’m listening to 100 different songs at the same time. And then with cannabis, it’s like putting on headphones and being able to focus on one specific song.”

More than anything though, cannabis has renewed Mandile’s sense of purpose and well-being. “Cannabis has helped my PTSD symptoms in so many ways: it’s allowed me to find purpose, it’s allowed me to find healing, and it’s the best tool I have to help me with pain, both mentally and physically,” he said.

Despite living in a state that had passed a medical cannabis law, Mandile’s road to access was not easy initially. He was able to get a medical cannabis patient card, but there were no dispensaries open to use it. Mandile turned to the illegal market at first, but he felt uneasy about coming off any of his prescription medications until he had access to a dispensary.

“I waited until June 2015 when the dispensaries first opened and knew I would have a reliable, consistent source of cannabis,” said Mandile. “After that it was about five months from starting until I was off of all those other medications, which included Ambien, Xanax, Fentanyl, Percocet, and a few antidepressants.”

Mandile has found a great alternative treatment for himself with medical cannabis, however, it was a path that he forged on his own. The VA and his other doctors were not guiding him in this treatment plan, so Mandile started doing his own research into different products and their effectiveness for his symptoms. In fact, Mandile states that even now—five years later—he is still experimenting with the right dose and products. “Although we do have access to a lot of great products, I go for what’s most affordable because I’m going from medications that I had paid nothing for—and in fact I’d earned through my service—to now having to pay out of pocket,” said Mandile. “I am on a fixed income with my disability benefits and Social Security, so I have to get what I can afford and I’m still trying to find the right method.”

“It’s pretty much trial and error,” said Mandile. “I had been keeping a journal to keep track of which products I was finding the most helpful, but after a certain period of time it became more about what was most affordable.”

Cost is a major obstacle for many veterans in situations like Mandile who live on fixed incomes and rely on the VA to help with their care after serving for their country. According to Mandile, current policy at the VA does not allow them to advise veterans on medical cannabis use. Mandile pointed out that this lack of information from reliable sources about the benefits of medical cannabis is another challenge. “I think many veterans are aware of the benefits, but there’s so much work to do to make sure more people know,” he said.

Mandile discussed how the VA in his area has become more receptive to cannabis lately. “In October, I spoke at a VA symposium on alternatives to healing and they specifically asked me to speak about the benefits of cannabis use,” said Mandile.

“The VA’s stance does vary from location to location though,” explained Mandile. “Massachusetts, Rhode Island, and the Northeast are pretty open to it, but some other VA’s will make you feel like you are making a huge mistake. You’re breaking the law. You have morality issues. You can’t be trusted. So, it does vary from facility to facility.”

Another obstacle that Mandile faced was that PTSD was not listed as a qualifying condition for a medical cannabis patient card in his home state of Massachusetts. According to Mandile, Massachusetts is the only state in New England that does not have PTSD listed as a qualifying condition and one of only seven states in the US (out of 33 at the time of this publication) with medical programs that does not have it listed. As a way around this, doctors in Massachusetts have the option to write in a condition under the “other” category, which was how Mandile was granted his medical patient card. However, Mandile explained that if someone was just looking to get into the program and didn’t see their diagnosis listed it might prevent them from looking into it further. As such, Mandile took this as a call to action and in the previous Massachusetts legislative session, he had a bill proposed that was going to add PTSD and opioid use disorder to the list of qualifying conditions.

Another aspect of the bill that Mandile submitted was to allow veterans in Massachusetts to be able to submit their VA paperwork to the state instead of having to go see another doctor. “I found that in North Dakota and Illinois, this is already the practice,” he explained. “A veteran doesn’t have to go to a doctor. They just submit their VA paperwork to the state and the state enrolls them in the program.”

Unfortunately, Mandile said that his bill got sent to study. This means that the Joint Committee is authorized to sit during recess and study the bill as well as similar ones and file a narrative report of its findings. However, the majority of bills that are sent to a study receive no further activity from the Committee (7).

Despite this, Mandile is not deterred. “We will be submitting a bill again this session to get those conditions added because being able to see them listed will also help break down barriers and destigmatize cannabis,” said Mandile.

The stigma around cannabis is another roadblock facing many veterans, as Mandile experienced first-hand with his own initial bias. He thinks that the stigma from prohibition at the VA is something that creates fear for every veteran. “Too many veterans believe, and I think this is from actual occurrences, that they can lose benefits for using cannabis, which was the case at one point,” said Mandile. However, he said that current VA directives have changed so veterans won’t lose their benefits or medications because of cannabis use.

Veterans do have other concerns about admitting to cannabis use such as losing their Second Amendment right to carry arms. Mandile explained that he got his license to carry at the same time he received his medical cannabis card, but still did not have a dispensary to go to. “I was still on all my other medications and there was no place for that to be listed on the application to carry but there was a spot for cannabis,” said Mandile. “So, it was okay for me to be on fentanyl, Xanax, and Ambien and have a firearm, but it was not okay for me to be using medical cannabis and have a firearm.”

As many people know, cannabis is still considered federally illegal in the US and it is listed as a Schedule I drug by the United States Drug Enforcement Administration (DEA). A Schedule I drug according to the DEA is a drug with no currently accepted medical use and a high potential for abuse (8), both of which have been proven false for cannabis through research and on-going studies around the world. This classification of cannabis is a major part of the problem surrounding the stigma of its use. It also restricts the level of research that can be done in the United States. Many researchers and advocates are pushing to have cannabis fully legalized in the best-case scenario or at the very least de-scheduled. This classification of cannabis explains some of the fear that veterans, and the general population, have about being added to a medical cannabis registry.

As a way around using a registry, some people don’t apply for medical cards and instead wait for adult use laws to pass in their states. “Adult use creates another pathway to access, but it really also helps break the stigma around cannabis,” said Mandile. “A lot of people also prefer to not be on a registry with a medical cannabis card, so this allows them to find cannabis treatments and maintain their privacy.”

Mandile’s experience with cannabis had such a great impact on his life that he felt a sense of duty to share his knowledge with other veterans and fight to make it more accessible. He related a story of one of his earliest experiences with cannabis that turned into an “aha” moment for him. Mandile was in his driveway in the winter after a snowstorm. He hadn’t shoveled or done snow removal of his driveway in a decade. This day, he decided to smoke a joint and go outside to see what he could do. He said he only wanted to shovel out or use his snow blower enough to get his truck out of the driveway. After an hour (and a second joint), he completed the whole driveway! “I couldn’t even get inside to tell my wife how amazed I was by it—I called her on my cell phone from the driveway and told her to look outside because I couldn’t believe what I just did,” said Mandile. “I thought, how is this possible? How is this not available? Why doesn’t everyone know about this?”

Mandile’s next thoughts went to all the sacrifices that his brothers and sisters in arms made. “It felt like my duty—my job—to help save the lives of my fellow veterans and make sure that they have every possible tool available to them,” he said. “If cannabis can help save one veteran’s life, then it is worth it. Cannabis is a tool that’s getting us to move in the right direction.”

From there, Mandile got to work and was able to get about a dozen medical dispensaries to start offering a 40% discount for veterans with a 100% disability rating. Another part of his work as a cannabis advocate led him to different cannabis events throughout Massachusetts. He had been continuously meeting with legislators as well as city and town officials for more than a year to share his story about how cannabis was so beneficial. He noticed that people were amazed by anecdotal stories such as his, but he felt that something was missing. He attended an event where Dr. Marion McNabb was speaking and realized that what he was missing was data.

After speaking with Dr. McNabb, they realized they could make a real difference working together. Mandile, Dr. McNabb, and Ann Brum formed the Cannabis Advancement Series to increase access to medical cannabis for veterans in Massachusetts. Dr. McNabb also led the charge for a data-driven study called the Veterans Health and Medical Cannabis Study (some of that data is presented in this special issue on page 6). Through this collaboration, the team presented their collected data and used it to drive the conversation at these curated community educational development events.

“It was eye opening for me to see how effective data is,” said Mandile. “People can say, ‘Yeah, that’s one person,’ when you’re telling your own personal experience, but when you have data on hundreds of veterans, your argument becomes that much greater. It’s not just hearts and minds. It’s numbers and actual statistics and research on it.”

Mandile describes his work as more than just advocacy—it has become his sense of duty and purpose, which for a long time he felt he’d lost. “One more thing cannabis brought me besides mindfulness was my sense of purpose and my ability to continue my service to my fellow veterans, my community, and my country,” he said.

He is careful to not over promise to his comrades though. He urges veterans to look at the facts. “I’m never going to tell a veteran this is going to make you feel better. This is something that’s going to work for you. We are all different. It works differently for each individual,” said Mandile. “But people need to really look at the statistics of the side effects on some of the medications we are prescribed—look at the bottle of your VA medication, you see some side effects of suicidal thoughts, coma, or even death. None of those come with cannabis. There are no reported overdose deaths.”

“Cannabis may not give you everything you want, but it may help take the edge off,” said Mandile. “It can be the gateway to healing.”

Mandile’s experience and dedication to helping others is inspiring. If nothing else, Mandile’s story and hundreds of others like him beg the question: Isn’t it worth investing time and research into medical cannabis as a treatment for the people that are willing to risk their lives for our country?

mayoclinic.org/diseases-conditions/post-traumatic-stress-disorder/symptoms-causes/syc-20355967

https://www.psychiatry.org/patients-families/ptsd/what-is-ptsd#:~:text=PTSD%20affects%20approximately%203.5%20percent,with%20PTSD%20in%20their%20lifetime

https://www.ptsd.va.gov/understand/common/common_veterans.asp

https://www.ptsd.va.gov/understand/related/suicide_ptsd.asp#:~:text=Studies%20show%20that%20suicide%20risk,and%20poor%20control%20of%20impulses

https://www.mentalhealth.va.gov/docs/data-sheets/2019/2019_National_Veteran_Suicide_Prevention_Annual_Report_508.pdf

https://www.masslegalservices.org/content/legislative-process-massachusetts-0

 is an Operation Iraqi Freedom Veteran in long-term recovery who advocates for policy change federally and in Massachusetts that provides pathways to healing and post traumatic growth. He supports all treatment and methods which help combat the disease of addiction, mental health issues, and improve the quality of life for veterans and non-veterans alike. Stephen also serves as a Selectman for the town of Uxbridge, Massachusetts, co-founder of the Cannabis Advancement Series, and the 2019 Veterans Health and Medical Cannabis Study.

Patient Focus

Gateway to Wellness: One Veteran’s Story of Healing Through Medical Cannabis

Ann M. Brum, founder and CEO of Joint Venture & Co., and Wayne Smith, veteran and veterans’ advocate, discuss their roles as cannabis advocates fighting for reform and veteran access to medical cannabis.

Post-traumatic stress disorder (PTSD) is defined by the American Psychiatric Association (1) as a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event such as a natural disaster, a serious accident, a terrorist act, war or combat, rape, or who have been threatened with death, sexual violence, or serious injury.

Although the American Psychiatric Association said PTSD affects approximately 3.5% of US adults every year, war veterans are more likely to experience symptoms of PTSD. As such, inside the US Department of Veterans Affairs (VA) is the National Center for PTSD, a research and educational center for PTSD and traumatic stress (2).

Many have heard the horror stories of soldiers returning from war with PTSD. According to an article published in 

, “The late and delayed effects of combat exposure in the form of PTSD were a significant source of suffering and disability among veterans in the United States. An estimated 700,000 Vietnam veterans—almost a quarter of all soldiers sent to Vietnam from 1964 to 1973—required some form of psychological help” (3).

However, hearing it from the point of view of Wayne Smith, a former combat medic in Vietnam and advocate for peace and justice, offers an intimate, raw, and vulnerable look at PTSD and his fight for veterans’ access to medicinal cannabis. In this article, Smith shares his personal journey with cannabis and his advocacy work. In addition, we spoke with Ann M. Brum, founder and CEO of Joint Venture & Co., to learn how she became interested in medicinal cannabis and her journey towards advocacy for veterans and medicinal cannabis access. Along the way, Brum and Smith joined forces to help educate their local communities, legislate laws in Washington, D.C., and fight for veteran access to medical cannabis.

A child of the 60s and the Civil Rights Movement, Smith was introduced to marijuana in high school. “The war in Vietnam was raging, and every young man was faced with the inevitability of do they go, or do they avoid service?” he explained. “Marijuana was introduced, and it was a period of young people shaking off the martini hours and the pattern of our parents who had a drink to get the same kind of relief that we got from marijuana.”

In 1969 in Vietnam, drugs like marijuana were popular, as alcohol wasn’t often used as a form of relief, relaxation, or even sociability. Smith and other soldiers would smoke marijuana after completing their assigned duties.

“We needed to wind down from the loss of friends and buddies; the horror of death was always with us—the stress was so enormous,” he said. “I never forgot how even in a combat zone, even in some of the greatest horrors that are indescribable to civilians, marijuana helped us feel more normal.”

But when Smith and other veterans arrived home from the war, it wasn’t a warm welcoming. PTSD wasn’t defined by the American Psychological Association until 1979, so Smith said veterans were left to their own devices to heal, treat, and process.

“Our country fully betrayed us,” Smith said. “The government sprayed carcinogenic toxins—Agent Orange—on us, so veterans were developing serious physiological health problems. There were high rates of depression among returning veterans, suicide was off the charts, and the VA was openly hostile to us.”

Veterans started forming self-help organizations in their neighborhoods and states. In Providence, Rhode Island, Smith and others formed a group called the Vietnam Era Veterans Association. And in 1977, Smith got his degree in psychology. Finally in 1979, the U.S. government created a series of programs called the Vietnam Era Veterans' Readjustment Assistance Act of 1979 with the VA to help returning veterans.

“I saw the kind of healing that was needed, and I was in the right place at the right time,” he said. “I was counseling veterans, and we were just helping one another, trying to come to terms with the trauma that we had experienced, trying to find meaning to life, and it was enormously difficult. But for those of us that used marijuana, it made a great difference.”

The problem was, men who used marijuana in the military and post-war were getting serious prison sentences. “They were sent to jail for having a couple joints, so marijuana wasn’t something we could openly talk about, but we used it very aggressively and copiously.”

Cannabis is still considered federally illegal in the United States, and it is listed as a Schedule I drug by the United States Drug Enforcement Administration (DEA). According to the DEA, a schedule I classification means that a drug has no currently accepted medical use and a high potential for abuse. This status for cannabis is highly disputed because of the medicinal benefits that have been well-documented and scientifically proven.

“There are no cases of suicide or overdose from cannabis,” Smith said. “Instead, there is a wealth of first-person accounts and science on cannabis’ ability to enhance and help one's ability to cope, relax, and enjoy life versus the lethal effects of alcohol.”

California was the first state pushing for change and legislation to legalize marijuana and make it accessible, and many Vietnam veterans were involved in pushing for legislation. “My involvement with the Iraq and Afghanistan Veterans of America has been one of the most rewarding ventures because this is a generation that understands the struggles Vietnam veterans had to go through—we had to kick in doors, demonstrate, and fight to have a hearing on alternatives to the powerful psychotropic drugs the VA gives out like candy.”

It’s not only taken a lot to change the country’s views on cannabis, it’s taken a lot to change how Vietnam veterans are viewed too. Smith and other veterans have worked hard to change people’s perspectives, which is something he’s very proud of. “Americans were able to finally separate the war from the warrior,” he said. “They looked at the individual soldiers and saw that after the shooting stopped, they came home and had real struggles to be like they used to be, and that meant getting help and treatment.”

Brum’s Story: Citizen Turned Veteran Advocate

Brum was first exposed to medicinal cannabis while working in hospice and end-of-life care. The agency used complementary therapies for veterans such as Reiki therapy, massage therapy, aromatherapy, singing therapy, and pet therapy—she was amazed by the patients’ relief. And one of her last patients was a former nurse who talked about how cannabis had helped her.

Fast forward to late 2015, through a vertically integrated medical operator, Brum was able to meet patients in the Medical Use of Marijuana Program in Massachusetts, which registers qualifying patients, personal caregivers, registered marijuana dispensaries (RMD), and RMD agents.

“Veterans were part of that patient population,” she said. “I received a lot of feedback from veterans on different types of products, dosing, their preferred method of administration, titration, and different cultivars that provided relief.”

A few years later, Brum was recruited to a medical patient provider that hosted, 

. During the event, cannabis leaders and professionals educated attendees on cannabis. The patient card provider gave qualifying veterans complimentary patient cards for the state cannabis program. From there, Brum launched a boutique growth agency, Joint Venture and Co., an organization dedicated to leaders who create industry movements with their teams and within the market.

Through various mediums, Brum connected with Tracey Gregory, an RN, and Stephen Mandile, an Iraqi war veteran and cannabis advocate, and the three of them presented at the Hospice and Palliative Care Federation of Massachusetts (2018 HPC FM) annual education conference on PTSD at end of life with veterans.

From there, Brum was introduced to Dr. Marion McNabb, DrPH, MPH—the CEO and co-founder of the Cannabis Community Care and Research Network (C3RN), a Massachusetts-based cannabis research company—who was eager to gather data on cannabis and veterans to present to legislators, industry, and the public. Shortly after, the Veterans Health and Medical Cannabis Study was born in collaboration with Brum, Mandile, and Dr. McNabb. The Veterans Health and Medical Cannabis Study is a comprehensive study, funded by various industry and media partners, that surveyed 565 veterans, both nationally and in Massachusetts, about various factors including age, wars served, military branch, symptoms, PTSD, treatments, medications, cannabis use, and more.

“It was the first time I was involved in an extensive study,” Brum said. “I’ve done surveys before but never at this scale in partnership with UMass Dartmouth for Institutional Review Board approval and future academic publications.”

In order to get the attention of legislatures, industry, consumers, veteran organizations, academics, regulators, and more, they founded the Cannabis Advancement Series as an awareness channel for the study in which the data was presented at curated community education development events.

“It was an incredible experience to collaborate with the founders Steven and Marion and curate important content, share veterans’ stories, and see their participation in the community, advocacy in cannabis, and entrepreneurship,” Brum said.

Smith was asked to be a keynote at the fourth installment of the Cannabis Advancement Series. The two met while Smith was presenting on a panel at the New England Cannabis Convention.

Both Smith and Brum continue to advocate for cannabis reform.

The findings from the Veterans Health and Medical Cannabis Study paved the way for Brum and others to advocate and petition for Bill H4274 at the Massachusetts State House. Their bill included two additional qualifying medical conditions for veterans and the general public: opioid use disorder and PTSD. PTSD is not considered a qualifying condition for a medical cannabis patient card in Massachusetts. It is one of only seven states with a medical program that does not have it listed.

Using the data from the study, Brum and others testified in January 2020 about their project and advocated for veterans to have a streamlined process to become a patient in Massachusetts.

“In terms of reform, we are only at the beginning of seeing the systemic impact these findings will have to inform legislators and constituents,” she said. “My hope is that moving forward, by legislative mandate, medical cannabis programs have a compassionate-use program that covers the costs for veterans to pay for their entry into the program with a patient card and offer an allotment or allowance to cover the cost of product—the barrier of entry and the barrier of cost are two complementary findings from our research and study findings.”

And for those veterans who received prison sentences for marijuana use, Smith, as part of his role as membership director of Vietnam Veterans of America, lobbied Congress for mental-health treatment methods and reduced sentences for veterans incarcerated for marijuana.

But still, Smith said the biggest misconception among Americans is ignorance. “People just don't know. Those who tend to be opposed to cannabis legalization and especially medical cannabis don't know about its benefits,” he said. “The VA is one of the largest consumers and dispensers of pharmaceuticals because they have the largest healthcare system in the country, over 250 hospitals. The biggest challenge continues to be the groundwork we are doing in Massachusetts and informing the American people to not be afraid, but to understand that cannabis has medicinal value, and it has changed and saved people's lives.”

As veterans and non-veterans alike advocate together, progress and change are happening, and they are inspiring others to get involved.

“We have helped to inform and inspire larger veterans’ communities, and they have come around in a very big way,” Smith said. “Stephen and Dr. McNabb were in Massachusetts blazing trails. I can't tell you how proud I am, as are other guys like me, old guys, who’ve been in the trenches for a long time, to see this next generation of leaders informed and using science. Stephen put his body on the line to help the people of Massachusetts understand that there are alternatives to gaining better control over their mental health and over their lives, to provide support and meaningful happiness to their families.”

Brum said she is always looking for opportunities to support those who are actively engaged like Mandile and Smith. “I’ll do anything I can to help support and raise awareness for veterans to have the access and choice of medical cannabis,” she said. “I will also continue to advocate at the Massachusetts State House and provide public testimony for the veteran community and policy around medical cannabis, as well as show up and support veteran organization initiatives such as the Massachusetts Disabled American Veterans Chapter and vote in local and state elections.”

Informing local communities and educating politicians, business leaders, and educators helps to diminish the stigma and fear around cannabis. “We have work to do at the state and federal levels. We need to push state legislatures that are less progressive than Massachusetts to come into the 21st Century,” Smith said. “And we will continue to lobby Congress and the White House to support practical, safe, and affordable treatment.”

“Show up and care enough to check in with veteran organizations, veterans, caregivers, and families” Brum urged. “There are amazing local, regional, and state organizations, as well as at the national level to participate and support. It’s about walking the walk and talking the talk. Show up, listen, learn, support, advocate, and vote. You’ve got to vote.”

Smith said people can get involved by supporting the work they do. “Contact Stephen Mandile or Dr. Marion McNabb. But more importantly, I hope every person who reads this calls their senator, congressperson, or state representative and asks two simple questions: Are you a supporter of medical cannabis? If so, thank you. If not, why not? It’s our civic duty,” said Smith. “We are asking people to stand with us to change the ignorance and to help educate people on the facts. We want to change public policy at the local and state level and change the government's opposition to doing the right thing and making medical cannabis available to every citizen who needs it.”

Brum, Smith, and many others continue to empathize, advocate, and educate for cannabis reform in hopes that current and future veterans and the general public can have access to cannabis’ medicinal benefits.

“I know suffering sucks; I’ve seen way too much with the loss of my father who was a foreign veteran from Portugal, serving on the islands of Azores,” Brum said. “I wish I had known about access or the benefits of cannabis or hemp in 2002 for his comfort and care.”

And Smith agreed. “It makes me wish that when I came home from Vietnam, there was a Stephen Mandile and a Dr. Marion McNabb. I think of how much better my life and the lives of so many other veterans that I've worked with over the years would be.”

Advocacy Focus

Ann M. Brum and Wayne Smith discuss their roles as cannabis advocates fighting for reform and veteran access to medical cannabis.

Cannabis Activism: The Fight for Veteran Access

Post-traumatic stress disorder (PTSD) affects approximately 3.5% of the United States population (1). According to the U.S. Department of Veterans Affairs, 11–20 out of every 100 veterans have PTSD (2). Nearly 300,000 veterans that have returned from Iraq and Afghanistan are currently suffering from PTSD (3). With those currently suffering and others being newly diagnosed, there will always be a need for medical professionals who are there to help.

Nurses play an integral role in any patient’s path to wellness, but perhaps even more so in the medical cannabis industry as nurses have been taking patient stories and their own experiences with cannabis to higher learning levels and raising awareness. There are many associations and groups dedicated to cannabis nursing and education, for example, American Cannabis Nurses Association (4) and the Cannabis Nurses Network (5).

One such nurse, Tracey Gregory, has been leading the charge for education and patient care in Massachusetts. Here, Gregory shares her personal experience with medical cannabis, veteran patients, and more.

Tracey Gregory is a registered nurse (RN) with more than 20 years of experience in various fields ranging from geriatrics, veteran education, special education, regulatory compliance, LGBTQ+ advocacy, and infection control. She first became interested in medical cannabis at a Hospice and Palliative Care of MA (HCPM) workshop several years ago, after which she did more research and became a patient herself. “I do believe that my first-hand knowledge of the effectiveness of cannabis and how it not only alleviated my symptoms but allowed me to drastically reduce, and in some cases, cease using other pain related medications, has provided me with the ability to provide more comprehensive education to patients,” said Gregory.

For the last 7 years, Gregory has been working at a hospice agency— Hospice of Western and Central MA—where she is responsible for quality assurance, staff education, and development. She was inspired to learn more about the specific needs of veterans during end of life when she became the lead person for the National Hospice and Palliative Care Organization (NHPCO) “We Honor Veterans” program. Gregory explained that the goal of the program is to provide hospice and community education and resources to address the unique needs of veterans and provide the best possible care at the end of their lives for those who served their country. Her agency currently has a 5 star level, which is the highest level available and a true testament to their dedication to veteran care.

Although it is seen as a newer method to treat PTSD, some veterans are making the switch from conventional treatment options to medical cannabis. Gregory said that in so many cases, medical cannabis has helped her patients reduce the need for pain and anxiety medications. This allows the veterans to work through their problems and have conversations about difficult experiences related to military trauma, without the heightened anxiety and avoidance symptoms of PTSD. “Using fewer narcotics and psychiatric medications also has the benefit of fewer side effects, such as constipation and lethargy and the added benefit of increased appetite,” said Gregory.

Gregory also explained that some anti-anxiety medications, such as, Ativan, cause a paradoxical effect—producing more agitation than reduced anxiety and calmness. “This can be because the veteran has the ingrained responsibility to be aware and alert and protect those around them. Something in the environment may trigger them to ‘action,’” said Gregory. “When given an anti-anxiety medication, it typically makes one feel sedated. In the veteran’s mind, however, their mission has not changed, and they must fight harder to stay alert. What may seem like terminal agitation may actually be PTSD.”

Medical cannabis treatment plans offer the ability to provide closure without over medication for end of life care. Gregory shared a story that took place several years ago with one of her patients that would not have been possible with traditional medications. A young veteran with service-related end stage cancer was admitted in October and his wife wished for him to survive long enough to have a last Thanksgiving. Gregory explained that because of the advanced stage of his cancer, he was not going to make it to Thanksgiving. Instead, his hospice nurse asked what his favorite holiday was and discovered that it was actually the 4th of July. So, they planned a family 4th of July picnic in October. “Using medical cannabis, he was able to sit with his wife on his porch and oversee his family and loved ones have a celebration,” said Gregory. “He was able to say his goodbyes individually while being comfortable and not sedated. Traditional medications such as morphine or Ativan would not have provided that opportunity, but medical cannabis did.”

The stigma surrounding medical cannabis deters some veterans from trying it. Generally, Gregory has seen the reluctancy among their older World War II (WW2) veterans. To them, it is still viewed as a “drug” instead of a medication prescribed by a doctor. Among Vietnam-era veterans, some avoidance exists because of a history of substance abuse (which is a common coping mechanism for PTSD). When they try cannabis, veterans typically see a reduction in their pain and anxiety symptoms, which also encourages continual usage. Reluctancy doesn’t just involve veterans, doctors and nurses have shared concerns as well.

“When I first started to provide education to other medical professionals on the existence and the function of the endocannabinoid system, there was increasing awareness but still reluctance on the use for our patients,” said Gregory. “At the time, there were few people who had heard of even CBD, of which now everyone is aware of. I noticed that the more they saw first-hand the effectiveness of the alleviation of symptoms and reduction in traditional medication, the more they supported it.”

The hospice center that Gregory works for participates in a program called “Hospice for Heroes” and takes serving these heroes very seriously on every admission. She explained that when asking a veteran any questions about their experience, her staff always first requests permission to discuss their military experiences because quite often a veteran does not want to talk about their experiences yet because it is too painful. “We are finding this more often with Vietnam vets. For example, it took one veteran almost 2 years before he felt safe enough to discuss his experiences with his social worker,” said Gregory. “The questions include branch of service, whether or not they saw combat, war served (if known) and other factors, including if they have a diagnosis of PTSD.”

Learning a veterans personal story is crucial to being able to best serve them at end of life. The information provided is often reviewed when difficulties in veteran care arise. Gregory related a story of one veteran residing in a nursing facility that would become agitated whenever the curtains around his bed were pulled open. When this incident happened, they reviewed his history and the information listed revealed that he had served as a medic on helicopters, so when the bed curtains were pulled open, it triggered his memories of the helicopter blades.

Gregory’s hospice also has a very robust Vet to Vet volunteer program in which fellow veterans offer assistance because not everyone may open up to a civilian for fear of judgement or knowing that only another veteran may be able to relate to their experiences. Hospice for Hereos also distributes framed certificates of gratitude to every veteran with a branch specific pin, thanking them for their service, which includes a personalized ceremony occasionally presented by a veteran volunteer. They also provide pet therapy and other holistic practices.

All staff and volunteers at the hospice receive veteran specific and PTSD specific training as well as how to actively listen to best provide support and healing at end of life. “I have recently added education based on Professor Brene Brown’s research on toxic shame,” said Gregory. “In veterans with shame surrounding their actions in service, staff are taught that being able to share these stories is not an indicator of weakness but of courage. When veterans share their painful experiences, we must respond in an appropriate way to not inadvertently further their shame but allow them to own their stories. It is a privilege to hear their stories.”

Gregory also started a special program with a late Vietnam veteran staff member called “Santa for Soldiers” with the mission to provide items at the holidays for veterans without families. “Many veterans with PTSD do not have family support due to their trauma and the effect on interpersonal relationships,” explained Gregory. “Our staff donate personal care items, clothing, and entertainment items such as puzzle books and DVDs.” In this program, the social worker or activities director at a facility decides who needs these gifts, which provides anonymity. The gifts can also be given to veterans that are not currently on their hospice service.

Tracey Gregory, RN, discusses her experiences with veteran patients with PTSD, her work with Hospice for Heroes, medical cannabis, and more.

November 2020

Cannabis Patient Care: Cannabis Medicine Personalized

The 2019 Veterans Health and Medical Cannabis Study

Gateway to Wellness: One Veteran’s Story of Healing Through Medical Cannabis

Cannabis Activism: The Fight for Veteran Access

A Nurse’s Account of Medical Cannabis Treatment

A Scientific Path to Discover the True Effects of Medical Cannabis

A Caregiver’s Perspective

Cannabis Patient Care November 2020 Volume 1 Issue 1