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Madeline Colli is the Associate Editor for Cannabis Patient Care and Cannabis Science and Technology magazines at MJH Life Sciences.
Tracey Gregory, RN, discusses her experiences with veteran patients with PTSD, her work with Hospice for Heroes, medical cannabis, and more.
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.
Battling in warzones throughout American history, every war brings a different experience. The technology changes, the war tactics, and landscapes continue to transform over time. The true number of how many veterans suffer from PTSD is hard to quantify with 100% accuracy because of those who do not know they have it and those who do not seek help on a diagnosis. In hospice, Gregory has seen that there is an increasing population of Vietnam veterans suffering from some level of PTSD. At end of life, PTSD can be triggered by numerous different factors. One common trigger is the feeling of helplessness, which has been a main contributing component. “As their terminal condition advances, they find themselves experiencing increased helplessness. They may become unable to be mobile, unable to express themselves verbally, become incontinent, and find themselves in a nursing facility where they have no control over who provides care for them,” said Gregory. “It may feel like they are actually back in the traumatic event because of the trigger of helplessness, even if they can’t connect it to the actual memory.”
Gregory has seen that medical cannabis has proven to be extremely beneficial for her hospice patients. Through her education and research, she has found that high tetrahydrocannabinol (THC) strains from the Cannabis Indica plant provides the most relief. Usually the products recommended are smoked, but if their conditions prevent that, such as those seen in respiratory conditions, edibles are generally used.
Since she works for an agency that receives federal payments and also because of federal regulations, Gregory’s hospice is not allowed to suggest or assist in the use of cannabis. Her facility is instead able to provide education to patients and families on how cannabis works. With that knowledge, she is able to review products found at their local dispensaries and offer recommendations on what might work or medical conditions and concurrent medications that may not be ideal for their situations. Gregory stated that although cannabis is a wonderful type of medicine, it should be treated as such and is not the right fit for every patient.
At her in-house community presentations for “Hospice for Heroes,” she goes over in detail the use and benefits of medical cannabis and PTSD. “Past community education includes a co-presentation at the HFCM with Ann Brum and Steven Mandile about the use of cannabis for PTSD and the process of obtaining a medical card,” said Gregory. “I was fortunate to be invited to serve on a panel at the Cannabis Advancement Series conference representing the needs of veterans with PTSD at end of life.”
In addition, to better serve their veterans Gregory provides a cannabis 101 presentation for all new hires and also to serve as ongoing education for staff. For nurses interested in exploring medical cannabis as a treatment option, Gregory recommended the American Cannabis Nurses Association as a platform for information and other resources (6).
Cannabis’s legalization is spreading across the United States. Although its popularity is rising, there are many states where it is still marked illegal. Where cannabis is not legalized, access to medical cannabis can be limited. Although the future status of cannabis is unknown, Gregory hopes to see that change in the future. “Currently, only our home patients can freely use medical cannabis, so I would love to see it come off the federal regulatory level so that those veterans that live in Assisted Living and Nursing Homes can have legal access,” she said.