Group 5 Many patients who are new to medical cannabis are often concerned with how addictive it could be. They’re also bombarded by both sides, one going down the old propaganda route of “It’s a terrible substance, on par with cocaine and heroin”, the other saying “There’s absolutely no harm or risk of addiction whatsoever.” Now, both are wrong, but it would be fair to say that the latter is “less wrong” than the former. In fact, the pharmacology of cannabis is complex enough that it may even serve as a treatment for drug addiction! However, this doesn’t mean there aren’t some potential issues regarding cannabis and “addiction”. They are … Photo of Ritalin, by Sponge. https://commons.wikimedia.org/wiki/File:Ritalin-SR-20mg-full.jpg The difference between “abuse” and “dependence” Over many years, there was a separation between “abuse” and “dependence” to a substance. Dependence refers to when a person becomes accustomed to a particular substance. Abuse is when a person starts using a substance separated from convention, for example according to physician recommendations. For example, a person who is taking vicodin as directed by their doctor is not necessarily abusing vicodin, but may become dependent upon it. On the other hand, a person who uses vicodin above-and-beyond what it was prescribed for, and is willing to put all other activities on hold in order to use vicodin, is said to be abusing vicodin. As for the term addiction, it refers to the use of a substance or activity to the detriment of all other activities (e.g. they’d rather spend money on the substance than eating properly). Often, words such as dependence and abuse were used interchangeably, and with such imprecise terminology regarding addiction, it becomes difficult to tell which one is which. So, around about 2 years ago, “drug addiction” became “substance use disorder” (SUD) in order to overcome this difficulty in understanding. Physical and psychological addiction Another popular distinction is physical/physiological and psychological addiction. Physical addiction – usually applied to opiates, barbiturates and alcohol – is where a person actually starts to need to ingest the substance they are addicted to order to stay alive. Alcohol, for example, suppresses the brain’s “fight-or-flight” hormones. With excessive drinking, the brain goes automatically into “fight-or-flight” mode as the alcohol leaves the body, leading to the “shakes”. Drinking large amounts of alcohol also desensitizes the brain’s GABA receptors, which then become prone to becoming “over-excited” when alcohol is withdrawn. This leads to seizures, which can be deadly. Cannabis abuse disorder When it comes to cannabis, “substance abuse disorder”becomes cannabis use disorder or cannabis abuse disorder, which affects around 9% of those who use cannabis. The reason why so many people say “cannabis is not addictive” is because they are referring to addiction in the traditional sense. There is no danger of extreme physiological responses (i.e. death) if use is suddenly stopped, and the psychological cravings generally seems to pale in comparison to that of cocaine or amphetamines. Yes, for some people, cannabis may disrupt their lives, but on the whole, it seems well-tolerated by most. Which brings us nicely onto the next point … Cannabis withdrawal For many, sudden cessation of cannabis is not too difficult. Some people feel irritable and may have a little difficulty getting to sleep, but after a few days or a week, tend to feel fine. Vivid rebound dreams are also common when cannabis use is suddenly stopped, and some people may sweat more profusely after giving up, or experience nausea. Some really unfortunate people may get a slight rise in temperature and “chills”. However, most people, even regular users, tend to have no major difficulty in quitting cannabis. A loss of appetite and nausea may also present themselves. The withdrawal is far from deadly, unlike with alcohol or opioid withdrawal. Symptoms of cannabis withdrawal usually appear between 1-3 days after stopping use, and generally peak in the first week of cessation. Most physical discomfort lasts about 2 weeks. Why is cannabis less addictive than other drugs and medications? What makes medical marijuana so special? So, what could be causing these “withdrawal” effects? And why is cannabis so much less addictive than drugs such as opiates and cocaine? The answer to both questions could very much be “dopamine”. The other answer is “the endocannabinoid system”. Many drugs give users a massive hit of dopamine. Cannabis does as well, but seems to do this via the ECS rather than directly affecting dopamine receptors, meaning it doesn’t necessarily produce the same “dopamine rush” that many other drugs do (although this is debatable). Also, as cannabis works via the ECS, the body can go back to its “baseline level” of dopamine rather quickly. The other interesting thing about cannabis – in particular THC – is that it can increase dopamine release and neuron activity, and blunt the dopamine system with long-term use. In essence, people can become more tolerant to THC, although this may be mitigated by: using a variety of cannabinoids; microdosing; using cannabinoid tinctures that have all their chemical bonds intact; and possibly “strain switching”. Remember: cannabis is biphasic, and the amount of THC used may also determine what impact it has on the dopamine system. The age at which one was exposed to THC in particular also seems to matter, as does how regularly THC is taken. Another reason why cannabis may not be as addictive as many other substances is because some cannabinoids, such as CBD, are also serotonin receptor agonists. There is some research suggesting that increasing serotonin levels may be a potential way of treating drug addiction, as many drugs deplete and blunt serotonin receptors over time. The complex pharmacology of cannabis means that it can have wildly different effects, including how addictive how it may be for someone. This also depends on which sets of cannabinoids and terpenoids are being ingested, and of course the individual’s physiology. Graph from Prof. David Nutt assessing drug harms. If tolerance builds, surely that’s physical addiction? There is a certain logic to this, but if we were to define physical addiction this way, then almost any substance could be seen as physically addictive, even though physiological dependence is not apparent. Yes, using THC may reduce production of and sensitivity to endocannabinoids, but once again, the “bounce back” of the ECS is rather rapid, meaning the body will start producing its own cannabinoids again rather quickly. The “physical” side of it never really takes a hold. Higher potency cannabis; should you be worried? Although ingesting high amounts of THC alone may not be physically dangerous, could it be argued that the increasing potency of many plants on the market today have “increased” cannabis’ “addictive” properties? As THC seems to boost dopamine production in the short-term, this could well be the case. Yet, cannabis is the most commonly used illicit medication, so surely if this were the case, we’d see many more people going to rehab centers due to cannabis use. This just hasn’t materialized, and there are many things cannabis users look for other than potency. OK. Maybe cannabis isn’t addictive, but surely it leads to other, more addictive substances? The gateway theory leaves a lot to be desired, at best; and, if we were to apply the gateway theory more fairly, it is alcohol and tobacco that could be said to be the bigger “gateway drugs”. There is some research out there suggesting that cannabis use may “prime” the brain for other drugs, as well as develop cross-sensitization with other drugs. There is also research suggesting that cannabis users may be more prone to trying other, more harmful substances, but that could be due to a person starting off on more readily-available substances and then interacting with people who use other substances. On the most part, though, most people who use cannabis tend to stick with cannabis. When it comes to medical use of cannabis in particular, it is unlikely that such people are going to start using more dangerous substances for recreational purposes. Medical cannabis is just that: medicine. What about an endocannabinoid deficiency? It is arguable that, if a person is using cannabis to overcome an “endocannabinoid deficiency”, it is likely that phytocannabinoids may be putting the body back into balance. This means that, with the right cannabinoid-terpenoid profile and dosage, rather than having a psychoactive effect, cannabis could be keeping the person medicating “normal”. Those who are using cannabinoids in such a manner are not necessarily addicted. Furthermore, if the patient is getting the right dosage of the cannabinoids they need, they may suffer from little-to-no withdrawal at all. In a sense, cannabinoids could be seen as similar to vitamins in some regards, where too much or too little can cause complications. That the cannabinoids that are used medically needn’t be psychoactive is also another huge plus – it’s very difficult to get addicted to a substance that has little or no psychoactive effect in most people! Is addiction inherited? Yes, it is, at least to a certain extent. Individuals who have a family history of addiction tend to be more prone to developing addiction, and this has been demonstrated in identical twins who were raised apart. There are also significant social and cultural factors that could make a person more prone to developing an addiction. Is cannabis as addictive as tobacco? No, cannabis is not as addictive as tobacco, which contains nicotine, and is very addictive. Although not a common practice in North America, in many other parts of the world, it is common for people to mix cannabis and tobacco. Some people who think they are “addicted” to cannabis are, in fact, addicted to the tobacco they’re mixing their cannabis with. Indeed, several experts have stated that cannabis is less addictive than coffee! Can cannabis be used as a treatment for addiction? We’ve already mentioned cannabinoids’ ability to modulate serotonin receptors, which is one way in which cannabis could be an “exit” from drugs, rather than a gateway. THC could also be a safer “crutch” than alcohol and opioids, and be used to replace the two. Beta-caryophyllene, which is a cannabinoid and CB2 receptor agonist commonly found in many cannabis strains, also has anti-addictive properties. Pharmaceutical drugs are often far more addictive than cannabis. So, is cannabis addictive? Well, a lot of it depends upon how you define addiction, but in the traditional sense, no cannabis is not addictive. In a more contemporary sense, overuse of cannabis can lead to addiction-like behaviors, but this level of addiction is not comparable to that of heroin, cocaine, nicotine or alcohol. Cannabis fails some of the tests it requires to be addictive and put in a Schedule I bracket.