Military veterans suffering mental health conditions are being denied potentially life-saving medicinal cannabis by blinkered practitioners and conservative decision-makers at the Department of Veteran Affairs (DVA), it has been claimed.
So acute is the issue of accessing legal cannabis, and of receiving subsidies from the DVA, that many ex-service personnel with Post Traumatic Stress Disorder (PTSD) are forced to source cannabis from the black market to ease their suffering.
It is feared the inability to access medication is putting further strain on already distressed veterans, some of whom are fed a cocktail of opioids and antipsychotic drugs that are “turning them into zombies”.
At the centre of the controversy is a refusal of the DVA to subsidise medicinal cannabis treatment for PTSD, with officials believing there is simply not the clinical data to warrant financial assistance.
Yet veteran advocates insist there is ample real world evidence to demonstrate the benefits that cannabis can provide.
Campaigners looking to build awareness of the issue are hoping a proposed Royal Commission into veteran suicides will provide a forum to highlight what they regard as the inadequacies of PTSD treatment.
Suicides among members of Australia’s defence forces has long been of grave concern, with official data from the Australian Institute of Health and Welfare (AIHW) showing 465 serving and former-ADF personnel took their own lives between 2001 and 2018. A further 13 have died this year.
Although yet to formally commit to a Royal Commission, the Morrison Government last month dropped its opposition to the move, bringing the prospect of a powerful enquiry an important step closer for veterans and their families.
The Australian Medicinal Cannabis Association (AMCA) is also exploring the creation of a veterans’ campaign. Chair and long-time cannabis campaigner Lucy Haslam will spearhead an initial fact-finding discussion next week with support groups, doctors, veterans and legal experts. It is expected to be a joint project with the Australian chapter of the Society of Cannabis Clinicians (SCCAC).
The struggle to access medicinal cannabis for PTSD sufferers has been illustrated by the case of Derek Pyrah, a veteran of the Iraq War who spent nine years in and out of hospital as he battled mental illness. During that time Pyrah was prescribed countless first-line medications, suffering numerous side effects, including suicide ideation.
But since turning to black market cannabis in 2015 – and switching to legal medicinal cannabis in November last year – Pyrah’s condition, and his quality of life, have dramatically improved.
Yet an application to subsidise his cannabis – which is temporarily being supplied free of charge by Entoura – was rejected in February by the DVA which insists there is “insufficient high-quality evidence” supporting medicinal cannabis as a treatment for PTSD.
Without that financial help, the former engineer has little hope of affording the medication – leaving his health to pay the price.
In a detailed resubmission to the DVA, Pyrah’s GP Dr Matty Moore argued medicinal cannabis has been the only treatment that has worked since he was first hospitalised in 2006, three years after returning from Iraq. His psychiatrist has also backed the use of medicinal cannabis.
“Initial self-medication with cannabis and subsequent prescription of medicinal cannabis has improved Derek’s signs and symptoms associated with PTSD without the ‘dulling’ effects of previous medications, and resulted in significant improvements in his sleep, fear reaction, suicidal ideation and mood,” the application states.
Meanwhile, previous issues triggered by polypharmacy such as weight gain, cholesterol and liver function have eased, while his societal interactions have “improved dramatically”.
“This has occurred without any suicidal ideation, displayed dependency or negative side effects,” the submission adds. “I assert there is clear evidence to support that in Derek’s case, medicinal cannabis provides the best opportunity for his recovery while improving his quality of life and reducing the risk of suicide.”
While acknowledging the lack of gold standard clinical trials in the area of PTSD demanded by the DVA, the application also documents numerous case studies and supporting data that has emerged in recent years.
It urged the DVA to follow its own framework of “demonstrating empathy for individual circumstances” and of dealing with applications on a case-by-case basis.
“The direct, real-life positive outcomes for this individual outweigh the value of published papers detailing the findings and experiences of others,” Dr Moore wrote.
The DVA has yet to respond to the resubmission.
In a statement to Cannabiz, the DVA declined to discuss Pyrah’s case but reiterated its position that evidence demonstrating the efficacy of medicinal cannabis in the treatment of PTSD remains scarce.
“Some scientific studies have shown medicinal cannabis to be effective in treating chronic pain in adults, chemotherapy-induced nausea and vomiting and multiple sclerosis,” a DVA spokesperson said. “In 2018, DVA developed a framework for funding medicinal cannabis for treating these conditions.
“Funding may also be considered for treating other conditions when supported by several high-quality scientific studies. Currently, some small studies have shown some benefit for mental health conditions, which is encouraging, but this evidence is limited and further larger studies need to be conducted to provide the evidence to support treatment of mental health conditions, including PTSD, with medicinal cannabis.
“As this research is rapidly evolving, DVA will continue to monitor the developing research and published evidence.”
The spokesperson added that as the Therapeutic Goods Administration (TGA) “does not vouch for the quality, safety or effectiveness of medicinal cannabis”, so the DVA, as the funder, remains concerned about such issues “and is bound by legislation to ensure funded treatments have an adequate evidence base”.
Lawyer Mat Henderson, who worked on the DVA submission along with Dr Moore and Entoura, said the inflexible approach was driving veterans to the black market and criminality.
Pyrah himself faced two cannabis possession charges in 2020 as he self-medicated. While the charges were proven at a court hearing, no conviction was recorded after the magistrate was satisfied it was for personal use, not for supply, Henderson explained.
“The DVA application should really be an open and shut case for Derek,” he told Cannabiz. “He’s been in and out of hospital for nine years, tried every therapy under the sun, and medicinal cannabis has been the only treatment that has worked. There is no reasonable alternative for him if he does not get the subsidy.
“The DVA cites a 2019 Lancet snapshot of scientific evidence [that says there is insufficient evidence], but that was using low-quality smokable recreational marijuana, not high-quality and standardised medicinal cannabis products with a more even cannabinoid content.
“High-quality evidence is multi-billion dollar, phase 3, triple-blind clinical trials, but we must remember that the current absence of this standard is not itself evidence of non-efficacy.”
Furthermore, the wait for such high-quality evidence could take 20 years, Henderson said.
In the meantime, “guys like Derek risk the return of suicidal ideation”.
Henderson added: “When veterans in such numbers are providing overwhelming empirical evidence that medicinal cannabis is helping them, and their long-term psychiatrists support those observations, that should be more evenly weighted against the supposed high-quality evidence which is still working its way through the labs.”
More optimistically, Henderson pointed to the “tidal wave of evidence” that will accompany applications from medicinal cannabis companies seeking to register Schedule 3 over-the-counter medication for conditions including insomnia and anxiety.
If the TGA is satisfied with evidence presented, and list medications on the Australian Register of Therapeutic Goods (ARTG), it is the DVA would have little options but to start subsidising PTSD patients with associated insomnia and anxiety issues.
“Veterans like Derek, who haven’t been taken care of by the chronic pain route, could be covered by insomnia and anxiety,” he said.
Nevertheless, that does not help veterans in the immediate future.
And according to Jason Frost, who served in the armed forces for 16 years and now helps fellow veterans navigate legal pathways to cannabis, the problem goes far deeper than DVA subsidies.
While that remains an on-going issue for PTSD sufferers, finding doctors to write prescriptions in the first place – or even to refer patients to specialist clinics – are also major barriers.
Too few in the medical establishment possess sufficient knowledge of the subject, too few want to learn and too many ignore real-world evidence and overseas research, Frost said.
The result is leaving veterans struggling to access legal medicinal cannabis and resorting to black market product, much of it of suspect quality. The alternative is the traditional cocktail of antipsychotic medications that are turning former ADF colleagues into a shadow of the people they once were, he said.
“There are some vets on 20 different medications for PTSD – 20, at the same time. It’s turning them into zombies. They can’t function as human beings. We are trying to get them on to some something that is natural, like CBD oil, but are told no. We’ve had doctors still call them party drugs, even with the education we have out there.
“Veterans are given hope there may be something that gives them relief and then every pathway they go down is a brick wall. It’s the last straw for too many guys.”
Frost, who suffers from chronic pain but whose quality of life “improved drastically” when he started taking medicinal cannabis in 2018, said many doctors are refusing to believe their own literature on the endocannabinoid system.
“For a doctor to say they don’t believe in it, they are going against their own literature,” he said. “They are not only refusing to prescribe, but refusing to write referrals that would put someone in a position to see a specialist who has done the training and knows about this medicine.”
Frost said he believed there was “external pressure” on the DVA not to entertain subsidies for certain conditions, including PTSD.
For Derek Pyrah, the wait goes on to see if the DVA will, as its capability framework suggests, display “empathy for his individual circumstance”.
Entoura general manager Clare Barker remains hopeful of a positive response, pointing out that while the DVA website precludes mental health from its list of subsidised conditions, its official framework did not set out such an exclusion.
“There appear to be inconsistencies in its position,” she said.
Barker added: “To seek high-quality evidence is okay from a policy position, but when you’re assessing the individual as you are supposed to do, why does that outweigh direct evidence from the doctors?
“I’m hoping the Royal Commission will create an opportunity to raise some of these issues. We also need to see what kind of campaigns could start to raise the profile and push a few buttons.
“We all have a strong belief in supporting our veterans.”