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Is cannabis an effective treatment for anxiety disorders?

With the growing legalization of medical cannabis throughout the United States, researchers are often tasked with answering the question of whether cannabis can be useful in alleviating conditions like anxiety-related disorders. Typically, cannabis use will likely worsen anxiety symptoms and interfere with evidence-based treatments, such as exposure therapy. However, preliminary research may suggest some positive benefits. For novice users looking to medical cannabis as an alternative method for anxiety reduction, using CBD is often a recommended starting point, so long as it is managed under the care of both a medical provider and mental health professional.

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The rise of medical cannabis in the United States has left many wondering whether jumping on the cannabis bandwagon is right for them. Often portrayed as a user-friendly substance that can help “mellow out” our responses to everyday life stressors, using medical cannabis for anxiety symptoms and disorders has been of interest to those seeking alternative treatment methods. Considering its controversial history, inconsistent research findings, and the current federal regulations around cannabis in the United States, answering the question, “will medical cannabis treat my anxiety?” is not so simple. Let’s explore the science behind cannabis, cannabis use, and the legal ramifications to getting a bit closer to answering the question “should I start using cannabis?

What is cannabis?

Cannabis, sometimes referred to as “marijuana,” is made up cannabinoids, which are naturally occurring compounds found in the Cannabis sativa plant. Cannabinoids act on cannabinoid receptors in the brain that make up the endocannabinoid system, which plays an important role in a host of bodily processes, including memory, perception of pain, mood, and appetite 1 . The two most commonly known and studied cannabinoids are tetrahydrocannabinol (THC) and cannabidiol (CBD), with the former being the principal psychoactive component of cannabis and the latter being a non-intoxicating compound 2,3 .

As a plant, cannabis can be manipulated to exhibit certain characteristics in the form of varying “strains”, including the two most polarized: sativa and indica. Sativa strains of cannabis have higher levels of psychoactive THC and lower levels of non-intoxicating CBD, while indica strains are the more “mellow” of the two with lower levels of THC and higher levels of CBD. However, strains are often blended to allow for more varied cannabis effects, while ingestion types and dosage also vary, making the consumption of cannabis a multifaceted practice 4 .

Cannabis – Fact v. Fiction

Given its tumultuous history and inaccurate and exaggerated portrayals in films and media, particularly as a result of the ongoing “War on Drugs” implemented by former president Richard Nixon in the 1970s, many misunderstandings, misinterpretations, and misrepresentations exist around cannabis and its effects. Some of the more common being:

  • Cannabis is a harmful drug that can lead to significant memory loss, lung disease, psychosis and/or death
  • Cannabis is a “gateway” drug and leads to more severe substance use
  • Cannabis is a highly addictive drug that is abused by many

In contrast, it is not uncommon for the benefits of cannabis use to be overstated by supporters, which can be misleading to those looking for alternative methods to alleviate difficulties with mood and anxiety. Recent surveys of the general population show that anxiety management is the second most endorsed reason for medical cannabis use 5 . Reports such as these suggest that those struggling with anxiety may be reaching for cannabis to treat their symptoms, which underscores the importance of reviewing the objective findings available on this topic. Common misconceptions among those in favor of cannabis use include:

  • There is conclusive evidence that cannabis can treat anxiety
  • There are minimal negative side effects of cannabis
  • Cannabis is safe for long-term use

What does the research say?

  • THC in cannabis has been shown to be more anxiety-inducing, while CBD has shown to be more anxiety-reducing
  • For chronic recreational users, cannabis use can lead to significant health risks, as well as increased anxiety particularly during withdrawal
  • Individuals suffering from PTSD or chronic pain have reported a reduction of anxiety-related symptoms when using cannabis medically
  • Small sample sizes and significant limitations in the research make it difficult to conclusively state the benefits of cannabis use in treating anxiety

Debunking some common myths, research on the risks of cannabis use has not shown a direct causal link between cannabis use and psychosis or death. Additionally, while cannabis is the most widely-used illicit drug and accompanies the use of other substances, determining its capacity as a “gateway” drug to more harmful psychoactive drugs has mixed findings 6 . However, a systematic review of research suggests that high doses of cannabis use can lead to addiction, psychosis-related health disorders in predisposed individuals, impaired cognition, and overall adverse effects on health outcomes and quality of life in long-term recreational users 2 . Such patterns of use have also been linked to cannabis use disorder (CUD) and cannabis withdrawal syndrome, which are characterized by a host of symptoms including irritability and anxiety 7,8 . In contrast, a meta-analysis of 23 randomized control trials found no evidence of higher adverse outcomes when patients were prescribed medical cannabis 9 . In fact, a study of 244 medical cannabis patients with chronic pain found that patients experienced a 64% decrease in opiate use, decreased amount and intensity of side effects of adjunct medications, and improved quality of life 10 .

Although some positive outcomes have been shown in those using cannabis for medical purposes, an analysis of the therapeutic utility of cannabis for treating anxiety symptoms has proven much more challenging. For example, we know that cannabis can have both anxiety-inducing and anxiety-reducing properties:

  • THC shows a greater tendency toward anxiety-induction.
  • CBD shows slight anxiety-reduction properties.

Specifically, THC has been shown to increase anxiety in animal studies 11,12 while CBD has demonstrated decreased anxiety in similar studies as well as in the treatment of anxiety caused by high levels of THC 13,14 . Similar opposing effects of CBD and THC were found in a neural activation study of 15 healthy men 15 . Despite these findings, sweeping conclusions remain unclear, making it difficult to parse out how different strains of cannabis use effect and interact with anxiety.

Although research has linked increased risk of panic attacks and panic disorder to cannabis use in some 16,17 , encouraging findings point to cannabis use as possibly alleviating anxiety in others, particularly through the use of CBD. For example, a double-blind randomized design study of 24 people with social anxiety disorder found that one 600 mg dose of CBD reduced performance anxiety and cognitive impairment in a speech performance 18 . A promising 2015 literature review showed that there is evidence that CBD is not only useful in social anxiety disorder, but in generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, and posttraumatic stress disorder 19 . A 2019 study found anxiety scores decreased with CBD over a month in 72 patients with anxiety and sleep concerns 20 . Another study from 2019 found perceived symptom improvement in 888 Canadian users of medical cannabis 21 In Washington, over 11,000 sessions recorded using the app StrainprintTM (which provides users of medical cannabis a way to track changes in symptoms) demonstrated a 50% reduction in depression and a 58% reduction in anxiety and stress following cannabis use with high CBD/low THC levels 22 . However, other studies have shown that individuals with social anxiety are more likely to abuse marijuana and that these individuals are more likely to experiences problems related to their cannabis use 19 . Additionally, a 2017 meta-analysis found no relevant association between cannabis use and anxiety symptoms in a general population sample 23 .

Results from studies investigating the administration of a synthetic form of cannabis (Nabilone) found a reduction of treatment-resistant nightmares in 72% of 47 patients with PTSD 24 . Nabilone has been demonstrated to have similar anxiety reduction in other anxiety disorders as well 25 . Furthermore, a systematic review of cannabis use in individuals diagnosed with PTSD found evidence of reduced restlessness, irritability, and sleep difficulties as well as reports of greater emotion regulation, reduced feelings of anxiety, and improved functioning overall 26 .

Other related articles about cannabis that you might find interesting:

Legal regulations for medical cannabis

Once a well-established and widespread treatment modality, the federal government began placing sanctions on the sale and cultivation of cannabis in 1937, with concerns about its psychoactive effects leading to its prohibition and classification as a Schedule I controlled substance in 1970 2 . Today, cannabis containing THC continues to be considered a prohibited substance under federal law, however, state legislators have found loopholes in the governing of cannabis use for both medical and recreational use. Beginning with California’s “Compassionate Use Act” (Prop 215) in 1996, today only four states – Idaho, Kansas, Nebraska, and South Dakota – have opted to not follow on the lingering smoke trail that is the legalization of cannabis in some capacity. Thirty-two states, along with Washington D.C., Guam, Puerto Rico, and the U.S. Virgin Islands, have departed from the federal government to impose their own individual laws and restrictions around the sale and use of medical cannabis, but the conditions for which medical treatment is approved varies from state to state 27 .

Most commonly used as an analgesic, appetite stimulant, and for controlling nausea and vomiting, medical cannabis is primarily recommended for individuals battling chronic conditions. The most common across states being cancer, HIV/AIDS, chronic pain, anorexia and wasting syndrome, seizure disorders (e.g., epilepsy), skeletal muscle spasms (e.g., multiple sclerosis), and post-traumatic stress disorder. Anxiety, in particular, is only explicitly named by New Jersey and West Virginia as a symptom or disorder to be treated by medical cannabis; however, many states have an “other” option for which physicians could determine anxiety as a qualifying condition 27 .

Given the disagreement in regulations between federal and state governments around the sale and use of medical cannabis, particularly THC-laden cannabis, there exists technicalities around what is and is not prohibited. For example, it is illegal for physicians to “prescribe” medical cannabis to patients under federal law and are only allowed to certify or recommend medical cannabis treatment for patients with state-approved medical conditions. In addition, reimbursement is not permitted by either federal or private health insurance companies for alternative methods, like medical cannabis, therefore those recommended for such therapies are required to pay in full for their treatment 27 .

Clinical Trials

Below are current trials investigating the effects of cannabis use on anxiety. See the link for more information.

  • Title: Cannabidiol for the Treatment of Anxiety Disorders: An 8-Week Pilot Study
    Sponsor: McMaster University
    Link: https://clinicaltrials.gov/ct2/show/NCT03549819
  • Title: Anxiety, Inflammation, and Stress
    Sponsor: University of Colorado, Boulder
    Link: https://clinicaltrials.gov/ct2/show/NCT03491384
  • Title: Sublingual Cannabidiol for Anxiety
    Sponsor: Mclean Hospital
    Link: https://clinicaltrials.gov/ct2/show/NCT02548559
  • Title: Cannabinoid Medication for Adults with OCD (recently completed)
    Sponsor: New York State Psychiatric Institute
    Link: https://clinicaltrials.gov/ct2/show/NCT02911324

Conclusion & Recommendations

Given federal regulations of cannabis in the United States, along with the recent boom of the medical cannabis industry, research on its effects are considered to still be in its infancy and unable to keep up with the demands of those seeking alternative therapeutic treatments. With the complexity of both symptomatology of anxiety and the effects of cannabis use, answering the question of whether medical cannabis is a safe and effective method of treating anxiety is a difficult task. More rigorous and controlled research is needed to provide more conclusive answers, so for now, the response to those exploring the options of medical cannabis treatment for anxiety symptom is to “proceed with caution!”

If you are experiencing anxiety that is impairing your daily life, we strongly urge you to reach out to a mental health professional specializing in the treatment of anxiety-related disorders so they may accurately diagnosis your anxiety difficulties and discuss evidenced-based treatments best suited for you. Currently, cognitive behavioral therapy is the most effective and first-line treatment for most anxiety-related problems, and it comes without the possible cost of side effects. Using cannabis or other substances to manage anxiety without the care of a doctor or experienced professional will typically interfere with therapeutic interventions and likely worsen your symptoms in the long run. However, if you are considering using cannabis to alleviate your anxiety, the picture is complex and its usefulness may depend on the chronicity and severity of your anxiety, as well as your history with cannabis use, other substance use, and psychiatric illnesses.

All things considered, the following recommendations should be kept in mind for those interested in pursuing medical cannabis treatment:

Can cannabis treat anxiety? It's complicated

M any cannabis users and businesses are invested in the idea of cannabis as an anxiety treatment. The position invites skepticism: marijuana companies have a financial interest in promoting a maximalist view of the drug’s benefits, and in patients it can look like a rationalization for excessive use.

As with other health conditions, the available research is inconclusive and limited due to decades-old restrictions on medical marijuana research. To sort through some of the ambiguities surrounding cannabis and anxiety, I spoke to Jordan Tishler, a Boston-area doctor who has a cannabis-focused practice.

One of the first things to keep in mind, he said, was the difference between anxiety and stress. Stress is a response to difficult situations such as a sub-optimal job or difficulty in one’s personal relationships. Many people who think of themselves as self-medicating for anxiety are actually self-medicating for stress. While this may be OK in the same context as an after-work cocktail, it may also enable users to avoid taking necessary steps to improve their lives.

Anxiety, Tishler said, referred more to a disorder when feelings of worry or distress arise for no specific reason. Fewer people take medical marijuana for generalized anxiety disorder (GAD) than stress, and the research about whether it works “is all over the map”.

Photograph: George Wylesol/The Guardian

“If you ask the average cannabis aficionado how you treat anxiety they will say they smoke throughout the day, ‘whenever you feel something’,” Tishler said. “That’s not the way we physicians approach something.”

The little research that does exist on the topic lacks specific information such as how much cannabis people take (dosing) and when in the day they ingest it. Additionally, the proportion of THC and CBD content of the product the subjects use is not clear. This makes it very difficult to gauge the drug’s efficacy. “People are very bad at reporting this stuff accurately,” Tishler said.

For those who take cannabis to relieve physical pain, it’s difficult to separate the intoxication from the desired benefit. But with anxiety, Tishler suggested the two could be distinguished. For example, ingesting a small amount of cannabis before bed can “create an [anti-anxiety] effect that outlasts the intoxication”. He suggested taking it in this way could also reduce the potential harms of an all-day habit, which range from lack of productivity to something more like cannabis dependence.

One of the driving forces of US cannabis legalization is the hope among military veterans that cannabis may relieve PTSD. “PTSD and generalized anxiety disorder have a lot in common,” Tishler said, and based on his practice he believes cannabis can be an effective treatment for PTSD. However, there is an added concern that veterans, in his experience, seem more likely to become heavy cannabis users very quickly, in part because they’re relying more on advice from their peers than their doctors.

Jonathan Avery, the director of addiction psychiatry at New York-Presbyterian hospital’s Weill Cornell Medical Center, didn’t dismiss the idea of cannabis as a treatment for anxiety, but he was more cautious. “We all know patients who have experienced relief from marijuana,” he said. But he said patients were more likely to have a good outcome with a psychiatric approach that can involve talk therapy and/or pharmaceuticals.

“It’s always complicated,” he said. It might help patients feel better but frequent users may be medicating the symptoms of cannabis withdrawal rather than anxiety. “And the evidence for marijuana’s benefits is not strong,” he noted.

But for some whose mood states and professional lives revolve around cannabis, more research isn’t necessary. They consider a plant, and especially this plant, inherently superior as medicine to a pill, just as almost all western doctors and virtually everyone else involved in healthcare believe the opposite. As with so many issues involving medical marijuana, the question is far from settled. And billions of dollars could change hands if the claims of cannabis boosters prove true.

Medical Marijuana Approved for Anxiety Disorder in Pennsylvania

Medical Marijuana Approved for Anxiety Disorder in Pennsylvania

The Sanctuary Wellness Institute medical marijuana cards evaluations at 5 locations in Pennsylvania – Philadelphia, Newtown Bucks County, Chester Springs, Lancaster and Camp Hill, PA

The Pennsylvania Department of Health added anxiety disorders to its list of approved medical conditions for the state’s medical marijuana program. This change went in to effect as of July 20th 2019 and has been well received by patients in Pennsylvania.

Medical Marijuana Card Doctor Evaluations are available at the Sanctuary Wellness Institute. Our doctor will evaluate your condition and is authorized to issue your card. We have offices in Philadelphia, Newtown, Chester Springs, Lancaster and Camp Hill.

Call (484) 346-5140 to schedule.

Medical Marijuana and Anxiety

Medical marijuana is used in the treatment of a wide array of diseases such as chronic pain, cancer, arthritis, depression, diabetes, glaucoma, migraines, epilepsy, Alzheimer’s, Parkinson’s, etc.

Alongside legalization, comes increased research surrounding medical marijuana’s efficacy as a medicine. More and more people are turning to medical marijuana in hopes of relieving or managing anxiety. Research in this area is still sparse, although there are some anecdotal and scientific reports of medical marijuana relieving symptoms of anxiety and stress.

The global medical marijuana market is expected to reach a value of US$44.4 billion by 2024, with a predicted growth of 22.9 percent between 2019-2024 (1). Twenty-six countries and thirty-six states in the USA have now legalized medical marijuana; these numbers will only continue to rise.

What Is Anxiety?

There are different forms of anxiety disorders. These include social, phobic, generalized anxiety disorder and post-traumatic stress disorder.

Diagnostic criteria and symptoms for each anxiety disorder differ. The WHO’s International Classification of Diseases note symptoms of:

  • Apprehensive thoughts, worrying about the future, difficulty concentrating and feeling on edge.
  • Motor tension, trembling, inability to relax, tension headaches, and restless fidgeting.
  • Autonomic overactivity, lightheadedness, tachypnoea or tachycardia, sweating, dizziness, dry mouth.

The prevalence of anxiety disorders globally ranges from 2.5 to 7 percent by country. There is estimated to be about 284 million people globally who experienced an anxiety disorder (2).

Typical Treatment for Anxiety Disorders

Treatment for anxiety disorders depends on the form and individual preferences, but it is usually treated with medication and therapy.

Doctors typically recommend stress management techniques. Stress management is achieved by organizing timetables, relaxation techniques like yoga, exercise, meditation, breathing techniques and writing down positive and negative thoughts. Counseling is also offered with trained mental health professionals.

Medications can help control the mental and physical symptoms of anxiety. Although most come with nasty side effects such as weight gain, drowsiness, nausea, sexual dysfunction and can be addictive. Cessation of some medications can also cause withdrawal symptoms.

The Endocannabinoid System And Anxiety

The modulation of the endocannabinoid system through the ingestion of medical marijuana influences a range of functions in the body, including those associated with anxiety.

Endocannabinoids are lipids produced naturally by the body and act as a neurotransmitter. These lipids activate CB1 and CB2 receptors in areas of the brain known to affect behavioral and emotional reactions, learning, memory, homeostasis and decision making.

Researchers have previously examined the role of CB1 receptors and discovered they play a key role in anxiety. They found deficiencies in natural cannabinoids result in an increased risk for the development of post-traumatic stress syndrome and depression. Supplementing this signaling system with low-doses of tetrahydrocannabinol (THC) – one of the active compounds in medical marijuana – helped to reduced symptoms of anxiety and increase patients resilience to stress (3).

Evidence For Medical Marijuana Relieving Anxiety

The interactions between the endocannabinoids system and anxiety disorders are not fully understood. More research is needed into whether medical marijuana is a suitable treatment for anxiety disorders.

During a recent study of 72 adults at a large mental health clinic in Colorado, researchers administered 25mg of the non-psychoactive cannabinoid CBD in the participants. The researchers found that 79.2 percent of the participants reported improvements in their symptoms of stress and anxiety (4).

Post-traumatic stress disorder is a psychiatric response to traumatic events. Evidence is mounting that cannabinoids might play a role in helping to decrease fear in people with this anxiety disorder, as well as have antidepressant effects (5). Some studies have reported a greater than 75 percent reduction of symptom scores following medical marijuana therapy (6).

Best Marijuana Strains For Anxiety

To properly treat anxiety, it’s important to use a medical marijuana strain with an appropriate ratio of CBD to THC. Although cannabis can decrease anxiety, in some people, excess THC consumption can exacerbate it due to the psychoactive effects of the plant.

THC is the compound which gives the psychoactive effect cannabis is most well known for. Consumed alone or in a higher ratio to CBD, THC can trigger the area of the brain called the amygdala, which is responsible for fear, which can induce fear and anxiety.

CBD, on the other hand, is non-psychoactive, meaning a user does not experience a “high” or any onset of euphoria after ingestion. CBD works antagonistically with THC, diminishing its psychoactive effects. In this sense, opting for strains with a higher or equal ratio of CBD to THC helps alleviate any anxiety giving properties of THC. CBD also has antipsychotic properties.

Summary

Medical marijuana has the potential for treating symptoms of anxiety. However, more research is needed in the area. The strain that works best will depend on the person using it. According to most anecdotes and scientific reports, CBD heavy strains tend to be best for reducing anxiety. Further research exploring the relationship between THC and CBD ratios is important so that doctors are able to effectively prescribe different strains to patients based on their needs.