Alibi V.27 No.32 • Aug 9-15, 2018 

Cannabis Manual

Rewriting the Trauma Story

An interview with Dr. Florian Birkmayer

According to the New Mexico Department of Health, 27,424 patients enrolled in the Medical Cannabis Program in June were suffering from Post-Traumatic Stress Disorder. This condition can seem nebulous to the laymen, so we sat down with Dr. Florian Birkmayer to get a better understanding. Dr. Birkmayer offers medical cannabis certifications and consultations in Albuquerque and the surrounding area.

Weekly Alibi: The majority of New Mexican cannabis patients say they are suffering from PTSD. What is the benefit of cannabis for these patients?

Dr. Florian Birkmayer: I have to start with where I'm coming from. I'm a psychiatrist. I worked for many years prescribing pills, and I did it in good faith thinking I want to help people. But especially for PTSD—there wasn't any drugs that were approved for PTSD. An anti-depressant would get approved and then the drug company would say, “Well it sort of works for PTSD, too.” All of these new drugs—they couldn't officially make any claims, but they would always say, “Try it for PTSD.” So it was really like throwing darts at a wall and seeing what sticks so that the status quo of PTSD treatment—at least on the pharmacological side—was very limited.

Eight years ago, when the cannabis program started, people would come to me and ask, “Can I try this?” And I've always felt that with psychiatry, we have to be pragmatic. We're just throwing pills at people, so what have we got to lose? And what's remarkable is that I've seen for years now that people have better control over their symptoms, many of them are able to come off their psych meds—and many of the psych meds have horrible withdrawal symptoms—so the drug companies are happy because you're a lifelong customer since it's so hard to come off them.

If I had to put it in a nutshell: People get their lives back. I had many patients who would take their pill and come to their appointment every month, but all they were doing was sitting at home, watching TV and smoking cigarettes, because either the medications were causing side effects or weren't relieving the symptoms.

I'm sort of a neuroscience geek. There's an organ in the brain behind the eyeballs on the temporal lobe on each side that's called the amygdala—they're little almond-sized organs—and it's kind of like a threat thermostat or a threat radar. It's preconscious. It takes your sensory input and decides if you’re in a threatening situation or not. It's doing its own thing—sort of like the sensors on your car that start beeping, and you don't know why.

That gets dysregulated in PTSD, so that if you've suffered trauma, you're always in this high alert setting. The amygdala is basically in overdrive, or hyperactive. And the cool thing is, it's actually covered in cannabinoid receptors, so when people are using cannabis, to me it's a more rational treatment for restabilizing the amygdala than just throwing some random Prozac or something at it.

So it starts for me with the clinical benefit—people are turning their lives around, able to get off psych meds, get their lives back and there's more rational science behind it for me than for the conventional psych pills.

In terms of PTSD—I think a lot of people with PTSD are burned out by the system, because they have that experience on the other side: “Oh here, try this pill. Try that pill. Try yet another pill.” And often their symptoms make it really hard to function. One symptom of PTSD that I find causes a lot of suffering is called “irritability” or “overreactivity.” If you think about it, PTSD is sort of like a hyperactive fight or flight response. There's flight—taking off—or fight—which is that irritability. And I think especially in Albuquerque, with the air force base, a lot of road rage in Albuquerque is actually PTSD.

So there's cannabinoid receptors on the amygdala? Are you saying that cannabis can somehow directly regulate it?

In terms of the dysregulation, there's quite a few studies out there. And in terms of the cannabinoid receptors—that's been established. In terms of someone measuring what it actually does, I have to admit I don't know. There are some studies for cannabis and PTSD, but I don't think they're actually measuring activity in the amygdala, so this is theoretical, but if there are cannabinoid receptors there …

… Then it would lead you to think that it binds there. So we're not sure about whether it treats PTSD directly, but does it treat the symptoms?

Again, I would say it gives them their lives back. When a trauma happens, it's not like there's anything you can do to go back and erase it—rewrite the videotape. So the real question is how do you deal with it? And with PTSD, if the trauma is overwhelming—and for different people, there's a different threshold—it has a negative impact on you. But the same event—with the right processing, let's say, you can actually integrate it into your life story in a more healthy way.

I think that cannabis allows people to—instead of being overwhelmed by the symptoms—it allows them to retell the story of their life saying, “Yes, this bad thing happened. Maybe I suffered for a year or 10 years, but now I'm in charge of my life again. I have control over the choices I make in my life. The symptoms aren't controlling my life.”

If you look at the oldest stories of mankind, like the Book of Job—which is much older than other parts of the Bible—or the epic of Gilgamesh, they're full of really traumatic events. Horrible things happen to Job and Gilgamesh is off with his friends fighting battles—and the descriptions of PTSD symptoms in Gilgamesh's epic are totally modern.

There's actually a study that came out 15 or more years ago that says the more coherent our narrative of a trauma is, the less our symptoms are. To me “cure” means that the story of your life gives you meaning. You can't go back and say, “That never happened.” But to say, “This horrible thing happened, and here's how I grew from it” is a better story than: “This horrible thing happened, and I've been hiding in my bedroom ever since.”

I think in that regard, cannabis really gives people the ability to rewrite their story.

It sounds like you're saying that cannabis makes the more emotionally overwhelming aspects of a trauma easier to analyze.

Exactly. I think with trauma, there's the story of what happened and there's all the feelings you have attached to it, which are overwhelming. That's when people get triggered by a certain smell or sound or going to the place where the trauma happened. You get flooded with memories, flashbacks—where you see what happened in your mind's eye again. Some people who meditate have this notion of the “observer”—there's a part of our brain that always watches what's going on—and when we get triggered into PTSD symptoms, it's like the symptoms are a black hole and we get sucked in, and the observer disappears or falls unconscious. And on a psychological level, I think cannabis strengthens the observer so that as the sensory input—the triggers—are coming in, that observer is strong enough to say, “This is reminding me of the trauma, but I don't have to get sucked into the symptoms.”

I think often, the crude approach is to say, “I just want to be numbed out.” And that's why people use not just psychiatric medications, but drugs and alcohol to self-medicate to be numb. I don't think the cannabis makes you numb—and sometimes people will even say to me, “The cannabis makes me think about [the trauma].” I think it's because of that observer thing, and sometimes you just need to look at something, even though the survival instinct says, “I just want to be numb. I just don't want to think about it.”

So I think the fact that you can be triggered, but the cannabis strengthens the observer so you can say, “This is the here and now, and not back where the trauma was,” means it's allowing people to heal from it—to integrate it.

How does someone know they're suffering from trauma? Isn't it relative?

Trauma is really ubiquitous. The modern descriptions of it started it in the American Civil War and combat fatigue and shell shock in World War I. But those were the tip of the iceberg, and now we're realizing that there's many more forms of trauma and things that are traumatic. When a young man or woman goes off to war, you assume they had a normal life before and then this traumatic event happened, and how are they different before and after? But many of them grew up with horrible trauma as children—abuse and neglect. So there isn't a “before.” There's now this notion of “complex PTSD” and the symptoms that go along with that.

Often people think mistakenly, “I can't have PTSD because I wasn't a soldier” or “I wasn't a first responder at a car crash.” But I think there are more subtle forms of trauma that people growing up with it think it's normal—like emotional abuse or physical abuse.

Another form of trauma that is talked about very little is neglect. The obvious neglect is when some kid is found in a basement and has been locked up. But there are more subtle forms of neglect, where the child's emotional needs may not be met. The kid may be fed and not at risk of starvation, but no one engages with them in a way they need. People will say, “Yeah, my parents just weren't there,” but because there wasn't a “normal” before that happened, they don't think that's trauma.

The classic understanding of trauma is “one big thing”—going to war or, again, being a first responder—but the cumulative effect of continuous low-grade trauma, I think, is often much more damaging. When you talk to people about traumatic events—and it's not just the trauma, but how things were processed—the two terms that are in the DSM-5 and seem to be the hallmark is the sense of being “overwhelmed” and “helpless.”

How would a PTSD patient know if this is the right treatment for them?

Most people have some experience with cannabis. There's this sort of oral knowledge, where people experience it firsthand. For a lot of people it's through a friend or someone that they find out about it, and often they have to overcome their own bias from the propaganda that they've internalized.

A lot of people are willing to try cannabis in my experience that aren't willing to try psych meds, and in a way that makes sense to me. Because the psych meds—again, none of them are approved for PTSD, and the side effects can be horrible.

So I think anybody that wants to do something about their PTSD symptoms is a good candidate. And more and more, my clients aren't interested in smoking or even vaping it. They really want to take it in a more medical way. More and more people who renew are using edibles, oils, capsules and candies, because they don't want to be high, they want to be able to get a good night's sleep, be able to function.

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