As practitioners, every situation we treat is unique. Each person we work with requires a particular dosage and a particular cannabis cultivar. One particular cultivar might work well for a specific condition in one person and not in another. The Western medical model of a standardized dosage for each condition applied across the board for every person is not so useful when it comes to herbalism, and especially with cannabis.
Unfortunately, we do not have a lot of data on human studies with cannabis due to our federal laws classifying cannabis as a Schedule I substance. By the U.S. government’s definition, cannabis currently has no accepted medical use and a high potential for abuse. (Even though the government owns patents on cannabis and states the benefits of its neuroprotective and antioxidant properties in the patent application.) The best research on cannabis with human subjects is being done outside the United States. Many of the U.S. studies are conducted with pharmaceutical isolates of cannabis. When studies do use flowers, researchers ask subjects to self-report data rather than use the standard protocol of a double-blind study. That said, it is wise to consider any contraindications or potential concerns when using cannabis for medicine.
Cannabis is the fourth-most-addictive substance used by Americans; caffeine is number one, alcohol is number two, and tobacco is third. (Frankly, I would rank sugar as number one, but that’s a whole other discussion.) Presently, the addiction rate for cannabis is 9 to 10 percent. In comparison, cocaine has a 12 percent addiction rate and alcohol 15 percent. Functional magnetic resonance imaging (fMRI) readings in the brains of addicted chronic cannabis users show that areas of the brain light up in the same patterns as they do for other addictive substances, including alcohol, tobacco, cocaine, heroin, and sugar.
Like other addictive substances, cannabis increases the amount of the neurotransmitter dopamine in the brain. Dopamine is the reward chemical that says, “Do that again!” However, while other addictive substances gradually cause a decrease in dopamine receptors, which creates a tolerance and the need for more of that substance to gain the same pleasurable effect, cannabis does not decrease dopamine receptors. Its mechanism of addiction lies elsewhere.
Risk factors for cannabis addiction include initial use at an early age and use of more potent forms. The quicker and more intensely a substance delivers a high, the higher the risk of addiction. As more people use the recreationally available resin concentrate dabs, with THC levels as high as 90 percent, we may very well see the cannabis addiction rate rise.
Withdrawal symptoms from cannabis begin one to two days after cessation of use and include irritability, anxiety, decreased appetite, restlessness, sleep disturbance, and sometimes functional impairment. Symptoms usually peak at one week and persist for three to four weeks. After four weeks, cannabinoid receptors return to baseline, and symptoms disappear. It’s important to note that if people have been working with cannabis to treat anxiety, going through withdrawal might trigger anxiety, and those people may feel the need to start using cannabis again; they will need to ride out the withdrawal symptom of anxiety.
Cannabis as an allergen is, like any plant, specific to an individual. People can develop allergies anytime in life. Windborne cannabis pollen can cause hay fever–like symptoms (this has been documented in the midwestern United States). Touching the plant can cause topical allergies, and inhaling the vapor or smoke can cause respiratory allergies. Hempseed can also cause allergies in sensitive people.
Relaxation and relief from anxiety are two of the most widely reported motives for working with cannabis. Cannabis is generally an effective treatment for anxiety, but there are a few situations where cannabis can cause anxiety. Cultivars with high THC and low CBD can cause anxiety. Most personal-use cannabis has been bred to be high in THC with very little CBD. Some of these cultivars are bred for increased energy and alertness, and can sometimes result in “zippy,” anxious feelings. CBD mediates some of these negative effects of THC. As growers and consumers learn more about the plant, cultivars with a more balanced THC/CBD ratio are gaining favor.
Too large a dose of THC can also cause anxiety. You cannot lethally overdose on cannabis the way you can with opioids, but too much THC can mimic the feeling of a panic attack.
One symptom of cannabis withdrawal is increased anxiety. If cessation of cannabis medicine is too abrupt, the body will not have enough time to restart production of endogenous cannabinoids and receptors. Ideally, users should taper use to zero over the course of four weeks to allow the body to increase production of its internal endocannabinoids and receptors.
Cannabis is not meant to take the place of psychotherapy, cognitive or behavioral therapy, or other emotional or psychological work. Cannabis is best used in a supportive role, because one of the plant’s great gifts is fostering a sense of safety and well-being.
Cannabinoid hyperemesis syndrome (CHS) is characterized by cyclic nausea, vomiting, and abdominal pain in chronic cannabis users. The symptoms usually present in the mornings and in individuals under 50 years old who consume cannabis at least once per week for one year or more. Symptoms are sometimes alleviated by a hot bath or shower and abate with cessation of cannabis use. The antiemetic pharmaceutical haloperidol (Haldol) can also alleviate symptoms.
The cause of CHS is unknown, but a top theory is nerve-signaling dysfunction caused by overstimulation of either the CB1 receptor, the TRPV1 receptor, or both. Cannabis allergy is another possible cause.
CHS symptoms can also present in people who are going through withdrawal from cannabis. Additional symptoms of cannabis withdrawal are increased irritability and appetite, sleep disturbances, and depressed mood.
During acute cannabis use there is some deficiency in attention, working memory, inhibitory control, and decision-making ability; average IQ drops four to eight points. Long-term users develop a tolerance to some of the negative effects of high-THC strains, such as acute memory deficiency, delayed reaction time, and decreased perceptual motor skills. People do not develop a tolerance to the desirable euphoric feeling.
In studying the long-term effects of cannabis use in adolescents, there is no evidence for a difference in IQ and achievement between users and nonusers when adjustments are made for caregiving environment and tobacco use (tobacco use and environmental conditions play more of a role in IQ than cannabis use). Cognitive deficiencies seen in adults disappear within 25 days of cessation. There are, however, some concerns about brain maturation in chronic cannabis users under the age of 25.
Cannabis is anxiolytic, antiemetic, anti-inflammatory, antispasmodic, and anticonvulsant. It supports apoptosis, modulates the immune system, and modulates pain. Any effects of pharmaceuticals used to relieve these symptoms should be monitored; the dose of the pharmaceutical might have to be reduced. Studies show cannabis potentiates the effects of opiates and chemotherapy. Users of cannabis might need lower doses of chemotherapy, opiates, or any other pharmaceutical that affects the same pathways as cannabis.
If you are not growing cannabis yourself or do not know the grower, testing for pesticide contamination is crucial. Most commercially grown cannabis is exposed to chemical pesticides, fungicides, and petroleum-based nutrients. Some small-scale farmers also use these products. In the United States, pesticide use is not federally regulated at present, but a few states do have standards. In a recent study, 85 percent of cannabis flowers tested in Colorado were contaminated with pesticides.
Cannabis is a bioaccumulator of heavy metals, and soils where it is grown should be tested. Solvents used for extraction are another serious contamination risk. People who make resin concentrates at home often use butane, a known carcinogen that is not fully purged from the final product. One study found butane levels equal to terpene levels in extracts.
One cultivar of cannabis does not fit all conditions. The practitioner needs to understand the person they are working with and how particular conditions manifest within them. Learning which cultivars are appropriate for specific people and specific conditions is key to effective treatment.
In traditional Chinese medicine cannabis is viewed as depleting to chi or vital energy. If cannabis is to be used long term, add a regimen of nourishing food and herbs such as adaptogens (Reishi mushroom, ashwagandha, nettles, and many others) to offset these depleting effects.
There is no evidence that cannabis users are more at risk of depression than anyone else. The “antimotivational syndrome” of lethargy, apathy, and decreased productivity of cannabis users is a myth. No evidence exists for a causal relationship between cannabis and depression. Depressed individuals may be self-medicating with cannabis.
As with all new regimens, assessment of the liver’s detoxification function is important. Cannabis is eliminated in the liver through the same pathway as most pharmaceuticals. In a healthy liver, cannabis use alongside pharmaceuticals shouldn’t be a problem.
Drugs that inhibit that pathway can potentially increase the bioavailability of THC. These drugs include proton pump inhibitors, HIV protease inhibitors, macrolides, azole antifungals, calcium antagonists, and some antidepressants. Drugs that increase the pathway’s effectiveness may decrease the bioavailability of THC; these drugs include phenobarbital, phenytoin, troglitazone, and St. John’s wort.
CBD is eliminated through different detoxification pathways, the same ones used by the sedative clonazepam (Klonopin). If CBD is dominating these pathways and preventing the liver from removing the drug from circulation, oversedation from clonazepam could result.
Using more than 2 ounces of high-THC cannabis flower per week may increase the anticoagulative effects of warfarin (Coumadin).
High doses of either THC (up to 1 gram per day of THC) or CBD can cause diarrhea.
Drowsiness or sedation is dependent on dosage and cultivar. Both THC and high doses of CBD can cause sedation. The terpenes myrcene, linalool, and limonene are also sedating.
A dry mouth and bloodshot eyes are symptoms of cannabis use in some people. If the person has a tendency toward dryness, consider introducing moistening herbs such as marshmallow root in conjunction with cannabis.
In the United States, cannabis has been called a “gateway drug,” meaning it could make a user more likely to try harder drugs, like opioids. There is no causal evidence for this. Rather, evidence suggests that therapeutic cannabis actually decreases rates of tobacco, alcohol, opioid, and prescription drug use and is a viable ally for harm reduction. But you could say that cannabis is a gateway drug — into the world of herbalism.
Both acute and chronic use of cannabis cause low blood pressure. Acute cannabis use may cause tachycardia (increased heart rate) and hypotension (low blood pressure) initially. People at risk of tachycardia or low blood pressure should use caution when beginning a cannabis regimen. Chronic cannabis use can result in bradycardia (a slow heart rate) and hypotension. The switch from tachycardia to bradycardia usually takes 14 days of daily use of high-THC cannabis.
Cannabis use may cause hypotension (low blood pressure). When systemic blood pressure drops, some people are prone to orthostatic hypotension, an inability to increase blood pressure when a person moves from sitting to standing. This short-term inability briefly delays blood flow to the brain, so the person feels dizzy. After a few seconds the body usually readjusts. Orthostatic hypotension may occur with higher THC dosages. Systemic hypotension may result from chronic high-THC cannabis use.
In animal studies, animals that were given 50 to 100 times the psychoactive dose of cannabis showed a decrease in immunity. A psychoactive dose for a new cannabis user might be as low as 2.5 to 5.0 mg. A dose 50 times higher would be over 1 gram; nobody except a person fighting cancer regularly takes doses that high. No evidence exists that cannabis depletes the immune system when used at therapeutic levels. Normal immune systems have been seen in 20-year chronic smokers of cannabis.
Cultivars that are high in THC, low in CBD, and low in myrcene can be too stimulating for individuals and cause sleeplessness. A high-CBD strain doesn’t necessarily promote sleep. It can actually be stimulating. In a full-spectrum medicine, some terpenoids are stimulating (terpinolene and pinene) while others are sedating (myrcene, linalool, limonene). You will need to consider the constituents of the particular cultivar.
Nausea can be an unwanted effect of a high dose of THC. What is considered a “high dose” varies from person to person, but it is helpful to know this can happen. Animal studies have shown that cannabidiol (CBD) at low dosages decreases vomiting while higher doses of CBD increase it.
One of the gifts of cannabis is to help us open, neurochemically, into a sense of safety. But when some people use cannabis in a vulnerable time or place, they might feel resistance, which can manifest in a sense of paranoia. It is advisable, especially for new cannabis users, to begin with low doses in secure, comforting surroundings.
While there is documented occurrence of women using cannabis to mitigate pain associated with menstrual and reproductive issues, including migraines, cramps, and leg pain, it is not advisable to use cannabis during pregnancy. Given that the endocannabinoid system is involved in all neural development of a fetus, abstention from cannabis use is advised. When a pregnant woman consumes cannabis, THC and CBD do cross the placenta and reach the fetus (at an albeit low level of 0.8 percent of mom’s blood level). Limited use of cannabis for morning sickness or pain management should be weighed against potential risks.
Over the last several decades, cannabis use has increased in the general population while the incidence of psychosis has remained the same. Individuals predisposed to psychosis should avoid cannabis, or at least avoid strains that are high in THC, because THC mimics the effects of the disease by lowering both GABA and glutamate levels, both of which are lower in individuals with psychosis.
Studies show no decrease in lung function or increased risk of lung cancer in 20-year cannabis-only smokers. When cannabis is combined with tobacco, all the risk factors for tobacco appear because of tobacco. Chronic cannabis smokers have a modest risk of bronchitis, but upon cessation or use of a vaporizer the risk diminishes.
Synthetic cannabinoids (called Spice, K2, and dozens of other names) have made their way into the mainstream. They are a legal blend of various synthetic chemicals. (When the FDA declares one particular chemical in the blend illegal, manufacturers simply alter their formula.) Because synthetics are full agonists of the CB1 receptor, there is an increased risk of adverse effects because they bind more strongly and for longer than THC. The biggest risk is heart attack.
When used in the proper setting, cannabis can help us move out of our established patterns of thinking to allow unique opportunities for growth. When approached in a respectful and mindful way, and with a willingness to do our own internal work, we can expect to come away from an experience with cannabis different from how we began the journey.