Use of CBD Oil in the Treatment of Posttraumatic Stress Disorder

Background and Significance of the Proposed Project

Over 80% of Americans are exposed to a significant trauma sometime during their lifetime and approximately 7% will meet for a threshold diagnosis of posttraumatic stress disorder. PTSD is the most costly anxiety-related disorder and confers significant interference in work, social functioning, increased risk for other physical and mental health problems, and a four-fold increase in suicide rates compared to the general population (1).

Over the past two decades, trauma-focused psychotherapies for PTSD have been shown to outperform more traditional supportive psychotherapy or pharmacotherapy and have become the first line treatment for PTSD (4). Despite these advances, trauma focused treatments such as prolonged exposure therapy (PE) are associated with high rates of treatment refusal, and among those who do enter treatment, approximately 25% drop-out (4). These data highlight the need to develop PTSD treatment strategies that are both effective and more palatable to patients.

More recently, there's been considerable excitement in the press over the potential therapeutic use of cannabidiol (CBD) products in the treatment of a variety of physical and mental health problems.( Delta-9-tetrahydrocannabinol (delta-9 THC) is still illegal in most states because of its psychoactive abuse potential. In contrast, cannabidiol (CBD) does not convert to THC in the body and has negligible side effects relative to main stream psychiatric drugs (benzodiazepines and antidepressants) commonly prescribed for the treatment of PTSD. Mounting evidence from studies with rodents suggests that CBD may confer significant promising health-related benefits including anti-inflammatory, pain-relieving, anti-cancer, memory enhancement, and facilitation of fear extinction (see White (5) for a recent review).

The biggest success story for CBD use in humans to date comes from controlled randomized clinical trials demonstrating a 50% or more reduction in previously intractable seizures in children suffering from Dravet syndrome (6) and Lennox-Gastaut syndrome (7). Moreover, several controlled clinical trials have shown promising findings in reducing psychotic symptoms among patients with schizophrenia and among young adults displaying THC-induced psychosis (8).

Preliminary Evidence that CBD may offer promise in the treatment of anxiety-related disorders has started to emerge. A small pilot trial with 24 patients presenting with social anxiety disorder found that relative to placebo, a single dose of 100 mg of CBD oil led to lower levels of anxiety, cognitive impairment, and discomfort in their actual speech performance as well as their anxiety before the speech (9). Unfortunately, human treatment studies for anxiety-related problems is limited almost exclusively to single dose effects on an anxiety challenge task. Studies are clearly needed to assess the effects of multi-dose CBD treatments across the full spectrum of trauma and anxiety-related disorders such as posttraumatic stress disorder.

PROJECT AIMS

The overarching objective of the proposed project is to test the clinical efficacy of CBD in the treatment of posttraumatic stress disorder using a rigorous double-blind randomized clinical trial methodology.

Specific aims of the project include:

1. Compare the efficacy of an 8-week multi-dose regimen of CBD oil (300 mg/day) relative to placebo oil in reducing clinician and patient-rated PTSD symptoms at the posttreatment, one month, and 3-month follow-up assessments.

We predict that patients receiving CBD monotherapy will show significantly greater improvement in PTSD symptoms and functional impairment at the posttreatment, one month, and 3-month follow-up assessments relative to patients receiving placebo mono-therapy.

2. Examine predictors of patients' clinical response to the various treatment combinations.

We expect that the superiority of CBD relative to placebo will be more pronounced for patients showing more severe PTSD symptoms at baseline and for those showing significant sleeping difficulties.

3. Examine the perceived acceptability and patients' side effects profile of 8 weeks of daily CBD oil ingestion.

We expect that CBD-treated patients will show equivalent levels of side effects as those receiving placebo oil.

STUDY METHODS AND PROCEDURES

Participant Recruitment: 120 Participants between the ages of 18 and older will be recruited through several outlets including notices posted on campus, announcements on our research laboratory website and national organizations related to PTSD and its treatment.

Participant Screening: Participants will undergo a two-stage screening procedure. Stage 1 will be a brief structured web-based screening interview. Stage 2 will be a telephone-administered structured clinical interview (SCID-5) with an advanced UT doctoral student in clinical psychology. Participants meeting the following inclusion and exclusion enrollment criteria will be invited to take part in the study (see below).

NOTE: ALL STUDY PROCEDURES ARE COMPLETED AT PARTICIPANTS' HOMES. NO VISITS TO OUR RESEARCH LABORATORY ARE REQUIRED.

Inclusion/Exclusion Criteria:

1. Meets for a current DSM-5 diagnosis of PTSD as their "primary" mental disorder

2. Age between 18 to 70

3. Fluent in English

4. Willingness to provide signed informed consent online

5. No history of a suicide attempt in the past 6 months

6. No history of psychosis with the past 6 months

9. No history of current alcohol or substance use disorder within the past 6 months.

10. No current medical problems that would preclude safe ingestion of CBD oil 11. Willingness to refrain from other forms of Cannabis use during the 8-week treatment phase of the study.

12. Has home access to the internet.

Participant Informed Consent:

All study participants will be consented by the study coordinator or a doctoral student research assistant during the screening visit conducted over the phone. The online informed consent document will provide participants with information regarding the aims of the project, what they will be asked to do, any anticipated risks or benefits associated with participating in the study, as well as a clear statement that their participation is voluntary and that they may discontinue participation at any time.

Study Design Overview: The research plan is to conduct a Phase II double-blind placebo controlled randomized clinical trial comparing the efficacy of CBD oil (300 mg./day) versus Placebo Oil.

CBD/Placebo Dosing:

Nightly dosing of a hemp-derived formulation of purified CBD isolate or matching placebo solution daily for 8 weeks. Individual doses of CBD and placebo oil will be provided in identical individual plastic syringes. All patients, PI, and staff who interact with study participants will be blind to participants' assigned treatment condition.

Clinical Assessment Schedule:

Week 0 - Pre-Treatment Screening Visit: All enrolled study participants will complete from their home a clinical assessment battery consisting of (a) self-report rating scales over the Internet (see measures); and (b) a structured clinical interview (CAPS-5) with an advanced clinical psychology doctoral student using Zoom conferencing software over the internet.

Treatment Visits (Weeks 1 - 8) : During this phase, all study participants will (a) receive via Fed-Ex their weekly allotment of CBD/Placebo oil; (b) complete weekly clinical status assessments via the Internet (see measures).

Posttreatment Assessment Visit (Week 9): All participants will complete an online battery of clinical outcome measures identical to those administered during their pre-treatment visit (see outcome measures).

1-Month Follow-up Assessment Visit (Week 13) - All participants will be re-administered the complete battery of primary and secondary outcome measures (see outcome measures).

3-Month Follow-up Assessment Visit (Week 21) - All participants will be re-administered the complete battery of primary and secondary outcome measures (see outcome measures).

Outcome Measures

Primary Clinical Outcomes: The primary clinical outcomes will be (a) scores on the Clinician Administered PTSD Scale (CAPS-5) and (b) independent evaluator ratings of clinical status using the Clinical Global Improvement Scale administered at each of the three posttreatment assessment periods (Week 9, Week 13, and Week 21).

Secondary Clinical Outcomes: Several additional psychiatric outcomes will be assessed at each of the three follow-up assessment visits. These clinical outcomes and their respective measures appear below. Additional information on these measures is available in the accompanying cited publication for each measure.

- Patient-rated PTSD symptoms using the PCL-5

- Depression - Patient Health Questionnaire (PHQ-9)

- Life Impairment - Sheehan Disability Scale (SDS)

- Quality of Life - World Health Organization (WHOQOL-BREF)

- Substance Use Disorders - NIDA-Modified Alcohol, Smoking, and Substance Involvement Screening Test (NIDA M-ASSIST)

Data Management Data Management involves development of methods for ensuring that data collection instruments are programmed; data are properly collected; participants are tracked and monitored over the course of the study; data sets are documented and maintained; variables are created and documented; and main analyses are conducted. To enhance quality control, all data for the current study including demographic information, diagnoses, and participant and clinician rated measures will be directly entered into a HIPPA compliant electronic case report form (eCRF) using Qualtrics - a secure cloud-based platform designed exclusively for supporting HIPPA compliant data capture and storage. Qualtrics provides: (a) An intuitive interface for data entry with data validation; (b) Audit trails for tracking data manipulation and export procedures; (c) Procedures for importing data from external sources; (d) Automated export procedures for seamless data downloads to common statistical packages (SPSS, SAS, Stata, R) to facilitate data analysis; (e) automated and secure data back-up and storage to servers housed at the University of Texas Population Research Center (PRC). Dr. Telch in his role as Principal Investigator will serve as the Senior data manager and will meet bi-weekly with the biostatistician and research staff on issues related to data management.