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Cannabis & Anxiety
What to Know
Last Updated:  11.22.22

Key Benefits
The role that cannabis can play in treating anxiety is the subject of ongoing research. While there’s much more to learn, cannabis appears to minimize the symptoms of the full spectrum of anxiety disorders: generalized anxiety disorder (chronic anxiety, tension, and worry), panic disorder (unexpected or repeated episodes of intense fear), post-traumatic stress disorder (after being exposed to a traumatic event in which physical harm occurred or was threatened), and social anxiety disorder (overwhelming anxiety and excessive self-consciousness in everyday social situations).[1,2]

Cannabis has also shown promise in the management of anxiety caused by phobias. According to some studies, CBD enhances the effects of exposure therapy, enabling patients to dissociate certain stimuli from a fear response and cognitive behavioral therapy.[1]

Other related illnesses may benefit from cannabis treatments, too.[3] For instance, recent research suggests that cannabis may contribute to the treatment of obsessive-compulsive disorder. However, the effects were short-lived and involved low levels of THC combined with high levels of CBD.[4,5]

Cannabis can also help with complex maladies of multifactorial origin that include anxiety as a common component, such as Autism Spectrum Disorder (ASD).[6] Statistically, ASD affects one in 44 children, with boys being four times more vulnerable.[7] Traditional medication cannot address autism causatively but does target some comorbid symptoms, such as aggressive behavior or anxiety. Fortunately, evidence has been forming that CBD offers a low-side-effect alternative for patients.[8] 

A 2017 ASD study assessed the safety and efficacy of CBD and found that one-third of patients reported significant improvement, and more than half reported moderate improvement in ASD symptoms.[9] International studies with parent-reported outcomes showed a more than 60% improvement in behavioral symptoms, and adverse events mainly included difficulty sleeping and reduced appetite.[8, 10, 11] Randomized placebo-controlled trials are still sparse, but more clinical investigations are underway, showing favorable preliminary results. 

Overall, an increasing number of patients have reported that cannabis has proven to be an effective treatment for anxiety disorders and can be used as a holistic alternative to prescribed medications with fewer adverse side effects. Consulting with an expert cannabis clinician who can help choose the most suitable strains and dosing regimens will help ensure the most satisfactory outcomes.

Key Risks
In certain situations, and with certain products, THC use can lead to increases in anxiety, especially in people new to cannabis or those approaching cannabis alone, without an experienced support system. Some find that high THC strains cause them to become anxious or paranoid.[6] While the combination of THC and CBD seems to reduce temporary anxiety induced by THC alone, long-term impact of the effects is still a subject of sharp debate, in the medical community.[7]

In addition, it’s essential to understand that cannabis products contain compounds such as THC and CBD that can interact with prescription medications. Those interactions can be potentially dangerous, increase or decrease prescription medication efficacy, and might cause adverse events.[8,9]

These medications include antidepressants such as Zoloft (sertraline) and Paxil (paroxetine), antifungal medications such as itraconazole and ketoconazole, asthma medications such as Singulair (montelukast), and some heart medications, such as Plavix (clopidogrel). Potential medication interactions are just one reason an expert cannabis clinician should always provide cannabis care. 

Some research has also shown that long-term cannabis consumption may affect the gray matter in the brain. As a result of some observational data that noted differences in the brain nerves of those consuming large amounts of cannabis over time vs those who did not, caution is typically recommended, with teenagers in particular, due to potential long-term impact, which is not yet fully understood.

It’s also good to keep in mind that, for some individuals, the ability of cannabis to ease anxiety can lead to a tendency to rely on cannabis to eliminate distress on a regular basis, which may be a risk factor for problematic overuse.

Cannabis therapy for adolescents comes with specific challenges and uncertainties. Clinical trials among young individuals under the age of 20 are rarely performed. Therefore evidence-based recommendations for treating diseases emerging at an early age, like autism spectrum disorder, are sparse. Physicians must exercise caution when recommending cannabis to young patients and their families.

And of course, anyone using THC products should refrain from driving, operating heavy machinery, or engaging in any other activities in which intoxication might pose a health or safety risk to themselves or others.

Who Should Avoid Using Cannabis For Anxiety?
Adolescents, individuals with a history of psychotic, mood or anxiety disorders, women who are pregnant, or planning to be pregnant, and people with cardiovascular diseases should only consider cannabis care in consultation with an experienced, licensed cannabis clinician.[10]  

If you’re someone who suffers from anxiety disorders, it’s best to avoid strains with a high THC content. Products which contain a higher level of CBD and a low or moderate level of THC are better for people with anxiety, as CBD is known to have anxiolytic and relaxing properties.

How Cannabis Works To Relieve Anxiety
The endocannabinoid system is essential in limiting the impact of anxiety and can become impaired after stress exposure. In other words, a well-functioning endocannabinoid system is crucial in counter-balancing anxiety; it can soothe stress-related systems of nerves in the brain using specific messenger molecules (2-AG)[11], which are part of the brain's anxiety-managing endocannabinoid system.

These messenger molecules move along a brain path that connects an area that handles emotion to another area that helps us make decisions. As they move, they inhibit the movement of stress-related chemicals. Recent research has found that substantial stress can overwhelm the endocannabinoid system and allow anxiety-related chemicals to speed through the brain. Cannabis, in the correct dosing regimen, can help restore endocannabinoid system homeostasis and help to control stress and anxiety.

About the Endocannabinoid System
What is the endocannabinoid system? It’s complex—and rarely taught in medical school. But it can be helpful to think of the endocannabinoid system as one of the body’s master regulators.

Briefly stated, it’s a neuroregulatory system that keeps physiologic functions in balance or homeostasis. It plays a crucial role in inflammation, immune response, pain detection, the sleep-wake cycle, mood, memory, appetite regulation, reproduction, and fertility. It consists of three major components: naturally produced chemicals (self-made endocannabinoids acting as transmitters), the receptors those endocannabinoids bind to (located on neurons, immune cells, etc.), and the enzymes which synthesize and degrade these components.

The human body uses two naturally derived signaling molecules called endocannabinoids: anandamide (aka the bliss molecule) and 2-arachidonoylglycerol (2-AG). Endocannabinoids are structurally similar to, but distinct from, the cannabinoids found in cannabis plants, though they act on the same receptors.

Cannabinoids derived from plants are usually referred to as phytocannabinoids. These plant-based cannabinoids consist of a wide variety of active cannabinoid molecules, with nearly 150 discovered to date. The best known molecules are tetrahydrocannabinol (THC), tetrahydrocannabinol acid (THCA), cannabidiol (CBD), cannabigerol (CBG), or cannabinol (CBN).

In addition to these 150 cannabinoids, the cannabis plant produces hundreds more organic compounds called terpenes and flavonoids. These unsaturated hydrocarbons may not activate the endocannabinoid receptors directly, but they modulate and fine-tune the functions of the activated receptors. This effect (of interaction with the receptors and molecules is known as the "entourage effect."

The second component of the endocannabinoid system is the cannabinoid receptor. The biological effects of cannabinoids are controlled by dozens of known cannabinoid receptors, the most relevant being receptors 1 and 2. Cannabinoid receptor 1 is primarily located in the brain, while cannabinoid receptor 2 is present exclusively in immune cells throughout the body. If an endocannabinoid binds to a cannabinoid receptor 1 in the brain, it may help to relieve pain. In contrast, an endocannabinoid that attaches to the cannabinoid receptor 2 in the immune system might help relieve symptoms of inflammation; it can tone down pro-inflammatory markers like cytokines and interleukin.[19]

The third component of the endocannabinoid system are enzymes, which synthesize and break down endocannabinoids. While many enzymes keep the endocannabinoid system balanced, the ones of therapeutic interest are the fatty acid amide hydrolase (FAAH) and the monoacylglycerol lipase (MAGL). The body's endocannabinoid response can be improved by modulating these enzymes for therapeutic purposes.[20] As a result, the endocannabinoid system keeps our body balanced, and cannabis can help support its natural function.

How Cannabis Care Should Work
As the evidence grows, it’s increasingly clear: An ongoing partnership with a clinician is essential in order to use cannabis safely and optimally in the treatment of anxiety.[20-25]

An eo clinician or other expert cannabis clinician with a thorough understanding of your goals, medical record, current medications, and cannabis use history should be involved in formulating initial and ongoing product recommendations, doses, and times of use.

Questions?
Schedule a free consult with an eo team member today. Or email us at members@eo.care.

The content on this page is for informational purposes. Do not attempt to self-diagnose or prescribe treatment based on the information provided. Always consult a physician before deciding on the treatment of a medical condition.

Sources

  1. Blessing, E.M., et al., Cannabidiol as a Potential Treatment for Anxiety Disorders. Neurotherapeutics, 2015. 12(4): p. 825-36.
  2. Sachedina, F., et al., Medical cannabis use in Canada and its impact on anxiety and depression: A retrospective study. Psychiatry Research, 2022. 313: p. 114573.
  3. Bergamaschi, M.M., et al., Cannabidiol reduces the anxiety induced by simulated public speaking in treatment-naïve social phobia patients. Neuropsychopharmacology, 2011. 36(6): p. 1219-26.
  4. Mauzay, D., E.M. LaFrance, and C. Cuttler, Acute Effects of Cannabis on Symptoms of Obsessive-Compulsive Disorder. J Affect Disord, 2021. 279: p. 158-163.
  5. Szejko, N., C. Fremer, and K.R. Müller-Vahl, Cannabis Improves Obsessive-Compulsive Disorder-Case Report and Review of the Literature. Front Psychiatry, 2020. 11: p. 681.
  6. Chaste, P. and M. Leboyer, Autism risk factors: genes, environment, and gene-environment interactions. Dialogues Clin Neurosci, 2012. 14(3): p. 281-92.
  7. CDC, https://www.cdc.gov/ncbddd/autism/data.html.
  8. Silva, E.A.D.J., et al., Cannabis and cannabinoid use in autism spectrum disorder: a systematic review. Trends Psychiatry Psychother, 2022. 44: p. e20200149.
  9. Bar-Lev Schleider, L., et al., Real life Experience of Medical Cannabis Treatment in Autism: Analysis of Safety and Efficacy. Sci Rep, 2019. 9(1): p. 200.
  10. Aran, A., et al., Brief Report: Cannabidiol-Rich Cannabis in Children with Autism Spectrum Disorder and Severe Behavioral Problems-A Retrospective Feasibility Study. J Autism Dev Disord, 2019. 49(3): p. 1284-1288.
  11. Barchel, D., et al., Oral Cannabidiol Use in Children With Autism Spectrum Disorder to Treat Related Symptoms and Co-morbidities. Front Pharmacol, 2018. 9: p. 1521.
  12. Crippa, J.A., et al., Cannabis and anxiety: a critical review of the evidence. Human Psychopharmacology: Clinical and Experimental, 2009. 24(7): p. 515-523.
  13. Sarris, J., et al., Medicinal cannabis for psychiatric disorders: a clinically-focused systematic review. BMC Psychiatry, 2020. 20(1): p. 24.
  14. Arellano, A.L., et al., Neuropsychiatric and General Interactions of Natural and Synthetic Cannabinoids with Drugs of Abuse and Medicines. CNS Neurol Disord Drug Targets, 2017. 16(5): p. 554-566.
  15. Anderson, G.D. and L.N. Chan, Pharmacokinetic Drug Interactions with Tobacco, Cannabinoids and Smoking Cessation Products. Clin Pharmacokinet, 2016. 55(11): p. 1353-1368.
  16. Ebbert, J.O., E.L. Scharf, and R.T. Hurt, Medical Cannabis. Mayo Clin Proc, 2018. 93(12): p. 1842-1847.
  17. Marcus, D.J., et al., Endocannabinoid signaling collapse mediates stress-induced amygdalo-cortical strengthening. Neuron, 2020. 105(6): p. 1062-1076. e6.
  18. Zou, S. and U. Kumar, Cannabinoid Receptors and the Endocannabinoid System: Signaling and Function in the Central Nervous System. Int J Mol Sci, 2018. 19(3).
  19. Basavarajappa, B.S., Critical enzymes involved in endocannabinoid metabolism. Protein Pept Lett, 2007. 14(3): p. 237-46.
  20. Saeed, O.B., B. Chavan, and Z.T. Haile, Association between e-cigarette use and depression in US adults. Journal of Addiction Medicine, 2020. 14(5): p. 393-400.
  21. Reed, M.K., et al., A Failure to Guide: Patient Experiences within a State-Run Cannabis Program in Pennsylvania, United States. Subst Use Misuse, 2022. 57(4): p. 516-521.
  22. Balu, A., et al., Medical Cannabis Certification Is Associated With Decreased Opiate Use in Patients With Chronic Pain: A Retrospective Cohort Study in Delaware. Cureus, 2021. 13(12): p. e20240.
  23. Ware, M.A., et al., Cannabis for the Management of Pain: Assessment of Safety Study (COMPASS). The Journal of Pain, 2015. 16(12): p. 1233-1242.
  24. Asselin, A., et al., A description of self-medication with cannabis among adults with legal access to cannabis in Quebec, Canada. Journal of Cannabis Research, 2022. 4(1): p. 26.
  25. Slawek, D., et al., Medical Cannabis for the Primary Care Physician. J Prim Care Community Health, 2019. 10: p. 2150132719884838.
  26. Saeed OB, Chavan B, Haile ZT. Association between e-cigarette use and depression in US adults. Journal of Addiction Medicine. 2020;14(5):393-400.
  27. Reed MK, Kelly EL, Wagner B, Hajjar E, Garber G, Worster B. A Failure to Guide: Patient Experiences within a State-Run Cannabis Program in Pennsylvania, United States. Subst Use Misuse. 2022;57(4):516-521. doi:10.1080/10826084.2021.2019780
  28. Balu A, Mishra D, Marcu J, Balu G. Medical Cannabis Certification Is Associated With Decreased Opiate Use in Patients With Chronic Pain: A Retrospective Cohort Study in Delaware. Cureus. Dec 2021;13(12):e20240. doi:10.7759/cureus.20240
  29. Ware MA, Wang T, Shapiro S, et al. Cannabis for the Management of Pain: Assessment of Safety Study (COMPASS). The Journal of Pain. 2015/12/01/ 2015;16(12):1233-1242. doi:https://doi.org/10.1016/j.jpain.2015.07.014
  30. Asselin A, Lamarre OB, Chamberland R, McNeil S-J, Demers E, Zongo A. A description of self-medication with cannabis among adults with legal access to cannabis in Quebec, Canada. Journal of Cannabis Research. 2022/05/26 2022;4(1):26. doi:10.1186/s42238-022-00135-y
  31. Slawek D, Meenrajan SR, Alois MR, Comstock Barker P, Estores IM, Cook R. Medical Cannabis for the Primary Care Physician. J Prim Care Community Health. Jan-Dec 2019;10:2150132719884838. doi:10.1177/2150132719884838
  32. The use of cannabis products may carry unique risks for those who  “self-medicate” without professional guidance and could worsen subjective symptoms. 26 {Omar Saeed} [J Addict Med]
  33. A lack of healthcare professional guidance can result in inadequate symptom relief and frustrating patient-reported outcomes after cannabis use as adjuvant therapy. 27 {Megan K Reed} [Subst Use Misuse]
  34. Among patients suffering from chronic pain, certification in medical cannabis is associated with a decrease in opiate use along with physician intervention. 28 {Alan Balu} [Cureus]
  35. Experts agree; a physician should handle treatment prescriptions and follow-ups to ensure safety.). 29{Mark A.Ware} [The Journal of Pain].
  36. Self-medicating with recreational cannabis is not a safe substitute for supervised care by a doctor or nurse practitioner. 30 {Antoine Asselin} [Journal of Cannabis Research]
  37. Health care providers should monitor for health consequences of medical cannabis use, while also considering how medical cannabis could affect other prescription medications. 31 {Deepika Slawek} [J Prim Care Community Health]

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