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Drying and Curing Cannabis Buds [The Easy Guide]

Did you know that drying and curing marijuana buds is a critical post-harvest element? Why? It is a process that can significantly impact the taste and general quality of your cannabis crop.

It is easy to breathe a sigh of relief after harvesting your plants in the mistaken belief that the hard work has been completed. Alas, your job isn’t done just yet, because you have to cure and dry the cannabis as soon as possible.

Curing involves drying your cannabis buds slowly in a specially controlled environment. Next, you need to keep the dried buds in glass mason jars for a few weeks. Eventually, you will have marijuana that smells and tastes better and, perhaps more importantly, is a great deal more potent!

Before we provide you with a guide to drying and curing cannabis buds, let’s outline a few reasons why you need to dry and cure them in the first place.

Cannabis Curing Increases Potency

Why bother going through the entire growing and harvesting process unless you are intent on getting the most potent cannabis possible?

During a process known as biosynthesis, cannabis plants produce tetrahydrocannabinolic acid (THCA) and other cannabinoids. The process involves certain compounds getting converted into different blends. For instance, THCA becomes THC.

Failure to properly cure marijuana means it ultimately contains a lower level of THC and other cannabinoids. When you cut down your cannabis, make sure it is kept in temperatures between 60- and 70-degrees Fahrenheit.

It is also essential to maintain the right humidity level. By doing this, you facilitate the biosynthesis process and ensure your crop is laden with THC.

Curing Affects Flavor and Quality of Smoke

If you didn’t know, the pleasant and unique smell and flavor of cannabis you experience are due to its terpene content. However, these volatile and fragile compounds are in danger of evaporating and degrading even at very low temperatures. Companies that mass produce low-grade marijuana often use a rapid-fire hot cannabis drying process.

For better quality bud, use a slow curing process to preserve the terpene content.

When marijuana is poorly cured, it creates the ideal environment for enzymes and bacteria to break down unwanted materials. It also results in the breaking down of the unhealthy sugars formed when chlorophyll decomposes. These sugars and minerals are what cause the unpleasant throat burn you sometimes get from smoking.

Curing Preserves Your Cannabis

If you intend to store your cannabis for a long time, high-quality curing is essential. When you cure the plant correctly, you can store it in an airtight container for approximately two years without a significant loss in potency. Otherwise, it will lose its cannabinoid content and become more susceptible to mold growth.

How to Dry and Cure Your Cannabis

Learning how to dry and cure cannabis buds is an art form. If you live in a coastal region, it is hard to dry cannabis quickly. This is because of the high nighttime humidity in such areas. Marijuana in these locations is at high risk of mold attack. So, the best time to try and dry it quickly is in winter or fall.

If you live in a warmer climate or an area at high elevation, e.g., Denver, it’s a different situation. In Arizona and Nevada, the temperature can range from 28-115 degrees Fahrenheit during the year, with mainly low humidity levels.

Denver is located at 5,000+ feet elevation with a temperature range of 0 degrees Fahrenheit (and lower) to over 100 degrees in summer. For residents of such areas, particular attention has to be paid to the drying and curing process.

Ideally, a cannabis bud will react similarly to a marshmallow when squeezed between your fingers. If it is excessively dry, it will fall apart and become a dry powder. While it is relatively easy to dry and cure small amounts, there is a greater challenge associated with commercial quantities. Don’t assume there is a particular temperature, elevation, or humidity level you need to aspire to.

Even so, your drying room must be well ventilated with lots of filtered, fresh air coming in from outside. You will also need to take measures to ensure correct odor control for exhausted air. Please note that excessively low temperatures result in cannabis with a high chlorophyll level, especially when combined with poor airflow.

Growers like to water cure, freeze-dry, or dry ice cure their plants. However, in this guide, we will focus on a tried and trusted drying and curing method.

What Is the Best Way to Dry Cannabis?

Before you begin the drying and curing process, make sure you have all the equipment you will need. This includes:

  • Wide-mouth mason jars for all your plants
  • A drying rack
  • A hygrometer
  • Humidipacks

The last two are optional. However, they make things easier by measuring humidity and ensuring your weed doesn’t get too dried out.

You begin the drying process as soon as you harvest your cannabis. When growers cut down the marijuana, they immediately notice how sticky and wet the flowers are. This is an excellent indication of your plants’ intoxicating resin levels. However, if you leave things as they are, you invite bacteria and fungi.

One of the best ways to dry marijuana is first to cut 12-inch branches from the plants. Next, trim away the unwanted leaves, and hang the branches from coat hangers or even pieces of string! There is no need to invest in expensive equipment if you have enough space to hang the plants.


There is ‘wet trimming’ and ‘dry trimming.’ The former involves trimming the plants as soon as they are ripe. Cut off branches individually and use shears to trim down unnecessary plant matter. Don’t eliminate all the sugar leaves because their lower cannabinoid content makes them ideal for edibles.

Dry trimming is best used when harvesting on a commercial scale. This is where you cut off branches and hang them upside down from individual lines. Make sure you only trim and process them when thoroughly dry.

Dry trimming is preferable on a commercial scale, but many home growers opt for the easier method of wet trimming.

It is a trickier process than wet trimming because the sugar leaves are curled towards the bud.

No matter which method you use, make sure you get rid of the larger fan leaves to improve the appearance of the buds.

Also, your marijuana will become harsher to smoke if you allow too much leafy matter to survive. As a rule of thumb, you need to trim fewer leaves if you live in a region where humidity levels are below 30% on average.

Hanging Your Buds

The most crucial aspect of proper drying is to ensure your storage room is at the right temperature and humidity levels. Keep the drying room between 60- and 70-degrees Fahrenheit and ensure the humidity stays in the 45-55% range. It is okay to use a small fan to circulate the air; don’t point it directly at the cannabis.

Are you having problems keeping the temperature and humidity levels at the recommended ranges? If so, purchase a humidifier (or dehumidifier if necessary) or an air-conditioning unit.

Hanging your buds upside down is the best method when trying to dry cannabis.

However, you can also lay them down flat on a surface such as cardboard if space is an issue. If you do this, make sure you turn the buds every few hours to avoid wet spots. Also, as you have to check on your buds daily, make sure your grow room is easy to access.

You can purchase a specialized drying rack if you have the extra cash, which will dry your buds faster than the clothes hanger method. This is mainly because you remove the moisture-laden stems from the buds. If you live in an excessively humid area, mold is going to be a problem. In this scenario, it is wise to invest in a rack.

Do You Feel the ‘Snap’ of Dry Buds?

Depending on the conditions of the storage room, you should have fully dry buds in 7-12 days. You can still cure them if they are dried faster, although that particular process will take longer. Once the buds are ready for curing, you can snap off the smallest buds by applying minimal pressure.

You may feel slightly bendy larger stems, which means there is still moisture inside. That’s okay because the curing process causes the hidden water to work its way to the outside of the buds. If you have a large crop, you can place the branches in bins with the lids left off overnight.

Every day, slide your hand to the bottom of the bin. If there is more moisture than on the top, flip the branches over. Once the bottom feels the same as the top, you can put the lids on the containers.

Keep your bud fresher for long…

In most cases, you won’t need to ‘press’ the cannabis. However, if you grew nugs outside that look bushy, pressing them will improve their appearance. It is best to perform this practice 5-9 days after hanging them because you want slightly moist marijuana. Place the buds in plastic bags, roll them up, and squeeze them. Place the bags beneath pillows or something similar for a few hours.

Be careful when pressing marijuana. If you’re too forceful, the trichomes will burst and reduce the overall quality. After a few hours, take the cannabis out of the bags. You’ll notice that the buds are sticking to one another. Separate them and return them to the hangers to complete the drying process. You can repeat the trick every two days until you’re satisfied with the aesthetics.

Your 6-Step Guide to Cannabis Curing

Once you’re satisfied that your cannabis buds are dry enough, it is time to complete the curing process.

Step 1 – Separate Buds from Branches

Ideally, you will have completed this step already. If you haven’t, trim the buds and separate them from the branches.

Step 2 – Place Buds into a Container

You have put so much effort into the process that it would be a shame to get it wrong now. From now on, your primary goal is to ensure that your cannabis buds are stored in a controlled environment.

Ideally, you will now store the buds at a humidity of 60-65% and a temperature of around 70 degrees Fahrenheit. At this moisture level, the buds will feel dry on the outside but still have a softness to them.

Wide-mouth mason jars are by far the best storage containers for marijuana. You can find them online or even at Walmart! Purchase 32 oz jars as they can hold up to 1.25 oz of dried bud. You could invest in larger jars, but with this, you increase the risk of mold growth. Make sure you only fill the jar so that it is 75% full. You want to leave a little air at the top and avoid crushing the buds.

What you need to get started…

You need to shake the jar now and then. If the buds are sticking together when you do this, it means your weed isn’t dry enough for curing.

Other storage options include wooden, metal, or plastic vessels. You can use plastic bags in a pinch, but they degrade after contact with specific terpenes found in cannabis. Interestingly, some growers deliberately cure bud when it is a little wet on the outside to cause additional bacterial growth.

Generally, it’s best to avoid this tactic as it usually produces inferior quality marijuana that is harsher on the lungs.

Step 3 – Place Containers in a Dark Place

Ensure the mason jars are sealed and place them in a cool, dark, and dry spot. Hopefully, the exterior of your buds is not crunchy and dry. This would indicate that the moisture from the interior of the flower has rehydrated the outside. If the outside is too dry, it means your marijuana is too dry.

Step 4 – Regular Checks

During the first few days, make sure you open the jars several times a day to let the flowers breathe. This is a crucial step because you allow moisture to escape while providing more oxygen.

If you open the container and there’s a foul odor of ammonia, it is a sign of anaerobic bacterial growth. This happens when you try to store buds that haven’t dried thoroughly. If you do nothing, you will end up with moldy cannabis.

If you have a hygrometer, use it regularly to test the humidity of the container. The ideal humidity range is between 60-65%. Here’s what to do if the humidity level is outside this range:

  • Over 70%:Place your buds outside the jar for 12-24 hours.
  • 65-70%:Take off the jar’s lid for 2-4 hours, but keep the bud inside.
  • 55% or less:Rehydrate with a humidipack if you have one.

Leave your jars open for a few minutes with every check. After seven days, you only need to check your jars once every two days. If you believe your buds are too dry, leave them inside the jar for up to three more days. This will allow you to see if any moisture from the interior of the bud comes to the surface.

If you don’t have a humidipack, you can use organic matter, e.g., an orange peel, to rehydrate the bud. However, by doing so, you also increase the risk of mold growth.

Step 5 – Repeat All Steps for 2-3 Weeks

Your cannabis should be primed and ready for use after approximately three weeks in a mason jar. However, some experts believe that eight weeks of cure time is optimal. There are a few marijuana strains that benefit from a six-month curing process — if you can wait that long!

In most instances, curing does little for strain quality after six months. At this stage, it is best to create a long-term storage solution to ensure your cannabis remains potent.

The wide-mouth mason jars you used to cure the bud are ideal long-term vessels, too.

Alternatively, you can vacuum seal the cannabis or store it in tightly-packed mason jars. Don’t try long-term storage unless the marijuana buds have been curing for at least three months.

Step 6 – Pack in Portions and Weigh

If you intend to keep the marijuana for personal use, it’s good to invest in humidity packs. They will keep your marijuana fresh for a long time.

There are a host of low-cost cannabis scales available online. Choose a brand, weigh your cannabis, calculate your usage, and determine how long this batch will last you!

Final Thoughts on Drying and Curing Cannabis Buds

Back in the days of illegal marijuana sales, there wasn’t much attention paid to the drying and curing process. The goal was to sell as much cannabis as possible, which meant that a crucial process was neglected. This helps explain the low quality of the ‘brick’ weed that was on offer back then.

Today, the sheer level of competition in the industry means that marijuana producers have little option but to spend the extra time and money on drying and curing their products. Fortunately, no specialized equipment is needed, which means you can do it at home with the cannabis you grow.

Make sure you begin the process as soon as possible after harvesting. Otherwise, you risk reducing the quality of the plant. There is a fine line between over-drying and not drying enough. This is something you can only learn with practice.

How Long to Dry Weed After Harvest?

Various factors impact drying time. For example, small buds will dry faster than large, dense ones. Also, it will take longer to dry if you hang large branches because they hold the most water. Other factors include humidity, airflow, and temperature. Therefore, we can only give a ballpark figure of 7-12 days

How to Dry Buds Without Hanging?

Hanging buds to dry remains the most popular method. However, you can also place them flat on a surface such as cardboard. If you decide to try this drying method, make sure you turn the cannabis every few hours to ensure no wet spots.

How to Dry Weed Without Equipment?

Ideally, you will have a means of testing the temperature and humidity of the drying room. If not, you should wait at least five days before checking the moisture of the buds. Snap a bud off the branch. If smaller buds snap cleanly, they are ready for curing. If not, you’ll need to wait a few more days.

How Dark Does the Drying Room Need to Be?

The best conditions for drying cannabis involve a cool and dark place. It is best to keep the room in complete darkness as this helps remove the aroma and taste of chlorophyll. You are rewarded instead with delicious, aromatic marijuana.

What Is the Best Temperature and Humidity for Drying Cannabis?

Experts recommend keeping your drying room at between 60- and 70-degrees Fahrenheit. It is also best to ensure humidity stays between 55% and 65%. Invest in a small fan to circulate air and perhaps a dehumidifier if the room’s humidity level remains high.

Cannabinoïdes: effets chez le sujet sain et utilisation en thérapeutique

Cannabis sativa L. preparations have been used in medicine for millenia. However, concern over the dangers of abuse led to the banning of the medicinal use of marijuana in most countries in the 1930s. Only recently, marijuana and individual natural and synthetic cannabinoid receptor agonists and antagonists, as well as chemically related compounds, whose mechanism of action is still obscure, have come back to being considered of therapeutic value. However, their use is highly restricted. Despite the mild addiction to cannabis and the possible enhancement of addiction to other substances of abuse, when combined with cannabis, the therapeutic value of cannabinoids is too high to be put aside. Numerous diseases, such as anorexia, emesis, pain, inflammation, multiple sclerosis, neurodegenerative disorders (Parkinson’s disease, Huntington’s disease, Tourette’s syndrome, Alzheimer’s disease), epilepsy, glaucoma, osteoporosis, schizophrenia, cardiovascular disorders, cancer, obesity, and metabolic syndrome-related disorders, to name just a few, are being treated or have the potential to be treated by cannabinoid agonists/antagonists/cannabinoid-related compounds. In view of the very low toxicity and the generally benign side effects of this group of compounds, neglecting or denying their clinical potential is unacceptable – instead, we need to work on the development of more selective cannabinoid receptor agonists/antagonists and related compounds, as well as on novel drugs of this family with better selectivity, distribution patterns, and pharmacokinetics, and – in cases where it is impossible to separate the desired clinical action and the psychoactivity – just to monitor these side effects carefully.


Las preparaciones de Cannabis sativa L. se han empleado en medicina desde hace milenios. Sin embargo, la preocupación acerca de los peligros del abuso condujo a la prohibición de la utilización médica de la marihuana en la mayoría de los países en la década de 1930. Sólo recientemente, los agonistas y antagonistas naturales y sintéticos de los receptores de marihuana, como también compuestos químicamente relacionados, cuyo mecanismo de acción todavía es confuso, han vuelto a reconsiderar el valor terapéutico. Pero su empleo está estrictamente limitado. A pesar de la adicción leve a cannnabis y el posible incremento de la adicción a otras sustancias de abuso, cuando se combinan con cannabis, el valor terapéutico de los cannabinoides es muy alto como para no tomarlo en cuenta. Numerosas enfermedades como la anorexia, la emesis, el dolor, la inflamación, la esclerosis múltiple, trastornos neurodegenerativos (Enfermedad de Parkinson, Enfermedad de Huntington, Síndrome de Tourette, Enfermedad de Alzheimer), epilepsia, glaucoma, osteoporosis, esquizofrenia, trastornos cardiovasculares, cáncer, obesidad, y trastornos relacionados con el síndrome metabólico, por nombrar sólo algunas, están siendo tratadas o tienen el potencial de tratarse por agonistas o antagonistas de los cannabinoides o compuestos relacionados con ellos. Dada la muy baja toxicidad y los efectos secundarios generalmente benignos de este grupo de compuestos, desatender o negar su potencial clínico es inaceptable; hay que trabajar en el desarrollo de agonistas y antagonistas, y compuestos relacionados que sean más selectivos para el receptor de cannabinoides, como también de nuevos fármacos de esta familia con mejor selectividad, patrones de distribución y fármaco-cinética, y – en casos donde sea imposible separar la acción clinica deseada y la psicoactividad – igual monitorear estos efectos secundarios cuidadosamente.


Depuis des millénaires, des préparations à base de Cannabis sativa L. ont été utilisées en médecine. Dans les années 1930 cependant, des inquiétudes concernant le danger lié à l’abus de cette substance ont conduit à l’interdiction de l’utilisation médicale de la marijuana dans la plupart des pays. Ce n’est que depuis peu que la marijuana et les agonistes et antagonistes des récepteurs cannabinoïdes synthétiques et naturels, ainsi que les composés chimiquement apparentés dont le mécanisme d’action est encore obscur, sont à nouveau considérés comme ayant un intérêt thérapeutique. Leur usage est cependant très limité. Malgré la dépendance modérée au cannabis et la possible stimulation de la dépendance à d’autres drogues lorsqu’elles sont associées au cannabis, la valeur thérapeutique des cannabinoïdes est trop élevée pour être négligée. De nombreuses pathologies, telles que l’anorexie, les vomissements, la douleur, l’inflammation, la sclérose en plaques, les troubles neurodégénératifs (maladie de Parkinson, chorée de Huntington, syndrome de Gilles de la Tourette, maladie d’Alzheimer), l’épilepsie, le glaucome, l’ostéoporose, la schizophrénie, les troubles cardiovasculaires, le cancer, l’obésité et les troubles liés au syndrome métabolique, pour n’en nommer que quelques-unes, sont traitées ou pourraient être traitées par des agonistes/antagonistes des cannabinoïdes, ou substances apparentées. Au regard de la très faible toxicité et des effets secondaires généralement bénins de cette classe de produits, il serait inacceptable de négliger ou de nier leur potentiel clinique. Il faut au contraire travailler au développement de récepteurs agonistes/antagonistes des cannabinoïdes et de composés apparentés sélectifs, ainsi qu’à de nouveaux médicaments de cette famille plus sélectifs, avec un mode de distribution et une pharmacocinétique meilleurs. Et lorsqu’il est impossible de séparer l’action clinique désirée et les effets psychoactifs, il est simplement nécessaire de surveiller attentivement les effets indésirables.

Cannabis sativa L. preparations, such as marijuana, hashish, and dagga, have been used in medicine for millenia. 1 Investigations into the chemistry of Cannabis began in the mid-19th century, following a major trend in chemical research at the time, which centered on the quest for active natural products. Numerous alkaloids were isolated in pure form or partially characterized. Morphine, cocaine, strychnine, and many others were purified and used in medicine. However, most of the terpenoids – a major class of secondary plant metabolites, to which the plant cannabinoids also belong – were not isolated until the end of the century or even much later, and in many cases their purity was doubtful.

In 1840, Schlesinger was apparently the first investigator to obtain an active extract from the leaves and flowers of hemp. 2 A few years later, Decourtive described the preparation of an ethanol extract that on evaporation of the solvent gave a dark resin, which he named “cannabin.” 3 For a detailed history of early Cannabis research see ref 4. The chemical research on the plant cannabinoids and their derivatives over nearly two centuries is described in ref 5. It was, however, not until 1964 that ∆ 9 -tetrahydrocannabinol (∆ 9 -THC), the major psychoactive component of Cannabis, was isolated in pure form and its structure was elucidated. 6 Shortly thereafter it was synthesized and became widely available. These chemical advances led to an avalanche of publications on ∆ 9 -THC, as well as on cannabidiol (CBD), a nonpsychoactive plant cannabinoid. 7 However, concern about the dangers of abuse led to the banning of marijuana and its constituents for medicinal use in United States and many other countries in the 1930s and 1940s. It took decades until cannabinoids came to be considered again as compounds of therapeutic value, and even now their uses are highly restricted. Here we present an overview of the addictive and side effects of cannabinoids vs their therapeutic potential.

Addiction to canabis, and the influence of cannabis on addiction to other substances

Marijuana may produce mild dependence in humans. 8-12 This was shown to depend on the personality type of the addicts, 13 and can be successfully reversed by abstinence or treated by cognitive-behavioral therapy, 14 without the occurrence of major withdrawal symptoms. Cannabinoids act on brain reward processes and reward-related behaviors by a mechanism similar to that found with other addictive drugs. In animal models they enhance electrical brain-stimulation reward in the core meso-accumbens reward circuitry of the brain and neural firing of a core dopamine (DA) component and thus elevate DA circuit. In the reward-relevant meso-accumbens DA circuit. In some animal models they produce conditioned place preference (CPP) and self-administration. 15,16 Other studies, however, find THC to be a poor reinforcer, with no or little self-administration. 17

The abuse of other substances is influenced by the cannabinoids. The cannabinoid system is involved in alcohol-consumption behavior. Cannabinoid CB1 receptor agonists have been found to specifically stimulate alcohol intake and its motivational properties in rats. 18 The high ethanol preference of young mice is reduced by the cannabinoid receptor 1 (CB1) antagonist SR141716A (rimonabant) to levels observed in their CB1 knockout littermates. 19 Dopamine release induced by ethanol in brain was reduced by SR141716A, 20 which can explain in part the antiaddictive effect of the drug. Cocaine is another substance of abuse in whose acquisition and consolidation cannabinoids may be involved. High prevalence of alcohol dependence and cannabis dependence can be found in patients with cocaine dependences. 21 Marijuana smoking increases plasma cocaine levels and subjective reports of euphoria in male volunteers. 22,23 Furthermore, a recent genetic study found an association between an n triplet repeat polymorphism in the CB1 encoding CNR1 gene with cocaine addiction in the African-Caribbean population. 24 In another study it was found that withdrawal from repeated access or exposure to cocaine and then a reinstatement of cocaine-seeking behavior or a sensitized locomotor response to a single cocaine challenge, respectively, was potently reduced by pretreatment with rimonabant. 25 Similarly, acute administration of rimonabant blocked expression of nicotineinduced conditioned place preference. 26 Rimonabant also reduces nicotine self-administration, and may be effective not only as an aid for smoking cessation, but also in the maintenance of abstinence. 27 As the endocannabinoid system plays a role in nicotine addiction, 28 the potential of cannabinoid antagonists to treat it is self-evident. 29-31 Opiate and CB1 receptors are coexpressed in the nucleus accumbens and dorsal striatum, and the interaction between the two systems is well known. 32 The reinforcing properties of morphine and the severity of the withdrawal syndrome are strongly reduced in CB1-knockout mice 33 ; this observation opens an opportunity to treat opiate addiction with rimonabant, as noted with alcohol, cocaine, and nicotine addiction. 34,35

Negative effects of cannabis other than addiction

There are some negative effects of cannabis use other than addiction, most of them related to alterations of attentional and cognitive functions or other neuropsychological and behavioral effects. Most of them are noted as a result of early-onset cannabis use (during adolescence). 36 Electrophysiological measures have revealed long-term deficits in attention among cannabis users. 37 In another study, impairment both in cognitive function and mood following cannabis use was noted. 38 However, in another study, cannabis users and controls performed equally well in a working memory task and a selective attention task. Furthermore, cannabis users did not differ from controls in terms of overall patterns of brain activity in the regions involved in these cognitive functions. 39 Prenatal exposure to cannabis is associated with only minor impaired cognitive and attentional effects. 40-42 Cannabis use in adolescence increases the risk of schizophrenia-like psychoses. 43 Cognitive dysfunction associated with long-term or heavy cannabis use is similar in many respects to the cognitive endophenotypes that have been proposed as vulnerability markers of schizophrenia. 44 Also, evidence exists that cannabis use may trigger acute schizophrenic psychosis. 45,46 Cannabis was found to produce a broad range of transient symptoms, behaviors, and cognitive deficits in healthy individuals that resemble some aspects of endogenous psychoses. 46 Amotivational syndrome is a chronic psychiatric disorder characterized by a variety of changes in personality, emotions, and cognitive functions such as lack of activity, inward-turning, apathy, incoherence, blunted affect, inability to concentrate, and memory disturbance. The syndrome was first described in the 1960s among patients with a history of longtime cannabis use. 47 A useful animal model for this disorder was found in rat, where the cannabis-caused catalepsy-like immobilization is related to a decrease in catecholaminergic and serotonergic neurons in the nucleus accumbens and amygdaloid nucleus, and thus can serve as a model for amotivational syndrome. 48 In another study, heavy cannabis use was found to cause an amotivational syndrome in adolescents. 49 The treatment of cannabis use disorders has recently been reviewed. 12 However, the occurrence of amotivational syndrome as a result of cannabis exposure remains controversial. 50 The data from other studies do not support the hypothesis that marijuana impairs motivation. 51,52 Although most of the cannabis-related negative effects relate to its neuropsychologic and behavioral effects, other negative reactions to cannabis are sometimes found. For example, cannabis can cause acute pancreatitis, although the exact mechanism remains unknown. 53

Therapeutic uses of cannabinoids

Obesity, anorexia, emesis

Cannabis has been known for centuries to increase appetite and food consumption. 54 More recently this propensity of the drug was substantiated when the CB1 receptor was shown to have a role in central appetite control, peripheral metabolism, and body weight regulation. 55 Genetic variants at CB1 coding gene CNR1 are associated with obesity-related phenotypes in men. 56 In animals, CB1 receptor antagonism decreases motivation for palatable foods. Rimonabant administration caused suppression of the intake of a chocolate-flavored beverage over a 21-day treatment period, without any apparent development of tolerance. 57 CB1 receptors were found to be preferentially involved in the reinforcing effects of sweet, as compared to a pure fat, reinforcer. 58 Rimonabant selectively reduces sweet rather than regular food intake in primates, 59 which suggests that rimonabant is more active on the hedonic rather than nutritive properties of diets.

Rimonabant leads to significant weight loss in obese human subjects. Treatment with rimonabant was also associated with beneficial effects on different metabolic parameters and cardiovascular risk factors linked with overweight. 60,61 In clinical trials rimonabant was found to cause a significant mean weight loss, reduction in waist circumference, increase in HDL cholesterol, reduction in triglycerides, and increase in plasma adiponectin levels. 62 Patients who were switched from the rimonabant treatment to placebo after a 1-year treatment regained weight, while those who continued to receive rimonabant maintained their weight loss and favorable changes in cardiometabolic risk factors. 63,64 Rimonabant was shown to be safe and effective in treating the combined cardiovascular risk factors of smoking and obesity. 65 It also diminishes insulin resistance, and reduces the prevalence of metabolic syndrome. Many of the metabolic effects, including adiponectin increase, occur beyond weight loss, suggesting a direct peripheral effect of rimonabant. 66 Therapy with rimonabant is also associated with favorable changes in serum lipids and an improvement in glycemie control in type 2 diabetes. 67 The activity of rimonabant in the management of obesity has been described in recent reviews. 31,68 It has been approved for the treatment of obesity in the European Union, and is sold under the trade name Acomplia. Surprisingly, the US Food and Drug Administration has declined to approve rimonabant, primarily due to its slight potential to enhance anxiety and suicidal thoughts. The atmosphere of consternation of possible legal action due to side effects may have led to this decision.

The other side of the same coin is anorexia. While in obese populations weight loss is the main goal, in other populations, such as patients with cancer or AIDS, it is an immense problem. Dronabinol (synthetic THC, known as Marinol and approved for the treatment of nausea and vomiting in cancer and AIDS patients) is associated with consistent improvement in appetite. 69 It was found to be safe and effective for anorexia associated with weight loss in patients with AIDS, and is associated with increased appetite, improvement in mood, and decreased nausea. In clinical trials, weight was stable in dronabinol patients, while placebo recipients lost weight. 70,71 Dronabinol was found to be safe and effective for treatment of HIV wasting syndrome, 72 as well as in patients with Alzheimer’s disease 73 and with advanced cancer, 73,74 The possible mechanisms of these actions have been reviewed. 75 Cannabinoids have a positive effect in controlling chemotherapy-related sickness. 76 They are more effective antiemetics than the dopamine receptor antagonists such as chlorpromazinetype drugs. 77 Direct comparisons with serotonin (5-HT)3 antagonists, which are widely used as antiemetics, have not been reported. However, while these antagonists are not effective in delayed vomiting, THC is known to reduce this side effect of chemotherapy.

Cannabis has been used for millennia as a pain-relieving substance. Evidence suggests that cannabinoids may prove useful in pain modulation by inhibiting neuronal transmission in pain pathways. Considering the pronounced antinociceptive effects produced by cannabinoids, they were proposed to be a promising therapeutic approach for the clinical management of trigeminal neuralgia. 78 THC, CBD, and CBD-dimethyl heptyl (DMH) were found to block the release of serotonin from platelets induced by plasma obtained from the patients during migraine attack. 79 However, in other reports cannabinoids are much less successful in pain-relieving. In a clinical trial THC did not have any significant effect on ongoing and paroxysmal pain, allodynia, quality of life, anxiety/depression scores and functional impact of pain. These results do not support an overall benefit of THC in pain and quality of life in patients with refractory neuropathic pain. 80 Similarly, in an additional clinical trial, no evidence was found 81 of analgesic effect of orally administered THC in postoperative pain in humans. Other studies show much better results of pain relief. When THC was given to a patient with familial Mediterranean fever, with chronic relapsing pain and gastrointestinal inflammation, a highly significant reduction in pain was noted. 82 Mild improvement was noted with cannabis-based medicines for treatment of chronic pain associated with brachial plexus root avulsion. 83 In neuropathic pain patients, median spontaneous pain intensity was significantly lower on THC treatment than on placebo treatment, and median pain relief score (numerical rating scale) was higher. 84 It was also effective in treating central pain. 85 The administration of single oral doses of THC to patients with cancer pain demonstrated a mild analgesic effect. 86,87 Patients who suffer from pain also tend to self-medicate with marijuana. In an anonymous cross-sectional survey, 72 (35 %) of chronic noncancer pain patients reported having used cannabis for relieving pain. 88 Cannabis-treated AIDS patients reported improved appetite, muscle pain, nausea, anxiety, nerve pain, depression, and paresthesia. 89 Not only THC, but also other cannabinoids can potentially affect different types of pain. Nabilone is a synthetic cannabinoid approved for treatment of severe nausea and vomiting associated with cancer chemotherapy. 90 In Canada, the United States, and the United Kingdom, nabilone is marketed as Cesamet. A significant decrease in disabling spasticity-related pain of patients with chronic upper motor neuron syndrome (UMNS) was found with nabilone. 91 Another cannabinoid, ajulemic acid (AJA), was effective in reducing chronic neuropathic pain, 92 although cannabinoid side effects (tiredness, dry mouth, limited power of concentration, dizziness, sweating) were noted. Cannabimimetic effects with ajulemic acid in rodents have also been recorded. 93

The combination of THC with the nonpsychotropic cannabis constituent CBD has a higher activity than THC alone. 94 The CBD/THC buccal spray (Sativex) was found to be effective in treating neuropathic pain in multiple sclerosis (MS). 95 Chronic neuropatic pain can also be treated with cannabis extracts containing THC, or CBD, or with Sativex. 96,97 The latter also was effective in reducing sleep disturbances in these patients and was mostly well tolerated. 97 Sativex is the first cannabis-based medicine to undergo conventional clinical development and be approved as a prescription drug. It is efficacious and well tolerated in the treatment of symptoms of multiple sclerosis, notably spasticity and neuropathic pain. 98 Sativex has been approved for use in neuropathic pain due to multiple sclerosis in Canada [for reviews on Sativex and on pain see refs 94, 99, and 100].

Multiple sclerosis, neuroprotection, inflammation

Inflammation, autoimmune response, demyelination, and axonal damage are thought to participate in the pathogenesis of MS. Increasing evidence supports the idea of a beneficial effect of cannabinoid compounds for the treatment of this disease. In clinical trials, it has been shown that cannabis derivatives are active on the pain related to MS, 84,85,95,97,98 However, this is not the only positive effect of cannabinoids in this disease. In rat experimental autoimmune encephalomyelitis (EAE), a laboratory model of MS, THC, given once after disease onset, significantly reduced maximal EAE score. Reduction in the inflammatory response in the brain and spinal cord was also noted in animals treated with dexanabinol (HU-211 a nonpsychoactive synthetic cannabinoid). 101 In another trial in rats, all animals treated with placebo developed severe clinical EAE and more than 98 % died, while THC-treated animals had either no clinical signs or mild signs, with delayed onset with survival greater than 95 %. 102 WIN-55,212-2, another synthetic cannabinoid, also was found to ameliorate the clinical signs of EAE and to diminish cell infiltration of the spinal cord, partially through CB2. 103 Using a chronic model of MS in mice, it was shown that clinical signs and axonal damage in the spinal cord were reduced by the synthetic cannabinoid HU210. 104 To more fully inderstand the involvement of the endocannabinoid system in MS, the status of cannabinoid CB1 and CB2 receptors and fatty acid amide hydrolase (FAAH) enzyme in brain tissue samples obtained from MS patients was investigated. Selective glial expression of cannabinoid CB1 and CB2 receptors and FAAH enzyme was found to be induced in MS. 105 In mice with chronic relapsing experimental allergic encephalomyelitis (CREAE), a chronic model of MS that reproduces many of the pathological hallmarks of the human disease, a moderate decrease in the density of CB1 receptors in the caudate-putamen, globus pallidus, and cerebellum was found. These observations may explain the efficacy of cannabinoid agonists in improving motor symptoms (spasticity, tremor, ataxia) typical of MS in both humans and animal models. 106 Spasticity is a common neurologic condition in patients with MS, stroke, cerebral palsy, or an injured spinal cord. Marijuana was suggested as treatment of muscle spasticity as early as the 1980s. 107 In an experiment in mice, control of spasticity in a MS model was found to be mediated by CB1, but not by CB2, cannabinoid receptors. 108 In clinical trials, patients treated with THC had significant improvement in ratings of spasticity compared to placebo. 109 In one case report nabilone improved muscle spasms, nocturia, and general well-being. 110 In another case report, the chronic motor handicaps of an MS patient acutely improved while he smoked a marijuana cigarette. 111 THC significantly reduced spasticity by clinical measurement. Responses varied, but benefit was seen in patients with tonic spasms. 112 At a progressive stage of illness, oral and rectal THC reduced the spasticity, rigidity, and pain, resulting in improved active and passive mobility. 113 However, in other clinical trials, cannabinoids appeared to reduce tremor but were ineffective in spasticity. 114,115 Moreover, in one trial marijuana smoking further impaired posture and balance in patients with spastic MS. 116 The inconsistent effects noted might be due to dosedependency. Improved motor coordination was seen when patients with MS, seriously disabled with tremor and ataxia, were given oral THC. 117 In another study, cannabis extract did not produce a functionally significant improvement in MS-associated tremor. 118 Suppression of acquired pendular nystagmus (involuntary movement of the eyes) was seen in a patient with MS after smoking cannabis resin, but not after taking nabilone tablets or orally administered capsules containing cannabis oil. 119 There are also findings suggestive of a clinical effect of cannabis on urge incontinence episodes in patients with MS. 120 In the treatment of MS, as well as in pain reduction described earlier, there is a preferential effect of a THC+CBD combination (Sativex). 121 A mixture of 2.5 mg THC and 0.9 mg cannabidiol (CBD) lowered spasm frequency and increased mobility, with tolerable side effects, in MS patients with persistent spasticity not responding to other drugs. 122 Oromucosal sprays of Sativex significantly reduced spasticity scores in comparison with placebo. 123 Long-term use of Sativex maintains its effect in those patients who perceive initial benefit. 124 Zajicek et al originally reported that cannabinoids did not have a beneficial effect on spasticity; however, there was an objective improvement in mobility and some patients reported an improvement in pain. 125 Later the same group also found positive effects on muscle spasticity with prolonged treatment. 126 The subject has been thoroughly reviewed. 99,127,130

MS is not the only disease state where the neuroprotective potential of cannabinoids can be seen. In animal experiments, 2 weeks after the application of 6-hydroxydopamine, a significant depletion of dopamine contents and a reduction in tyrosine hydroxylase activity in the lesioned striatum were noted, and were accompanied by a reduction in tyrosine hydroxylase-messenger ribonucleic acid (mRNA) levels in the substantia nigra. Daily administration of THC over 2 weeks produced a significant irreversible waning in the magnitude of these changes, which may be relevant in the treatment of Parkinson’s disease (see below) 131 The cannabinoids have a neuroprotective activity not only in vitro but also in vivo: HU-210, a potent synthetic analog of THC, increases survival of mouse cerebellar granule cells exposed to 6-hydroxydopamine. 131 In a model of experimental stroke, rimonabant reduced infarct volume by approximately 40 %. Rimonabant exerted neuroprotection independently of its cannabinoid receptor-blocking effect. 132 In clinical trials, dexanabinol-treated patients achieved significantly better intracranial pressure/cerebral perfusion pressure control without jeopardizing blood pressure. A trend toward faster and better neurologic outcome was also observed. 133 However, in further experiments, dexanabinol was not found to be efficacious in the treatment of traumatic brain injury 134 A wide range of cannabinoids has been shown to help in pathologies affecting the central nervous system (CNS) and other diseases that are accompanied by chronic inflammation. 130,135,136 In a rodent model of chronic brain inflammation produced by the infusion of lipopolysaccharide into the fourth ventricle of young rats, the cannabinoid agonist WIN-55212-2 reduced the number of LPS-activated microglia. 137 Direct suppression of CNS autoimmune inflammation was seen by activation of CB1 receptors on neurons and CB2 receptors on autoreactive T cells. 138

Atherosclerosis is a chronic inflammatory disease, and is the primary cause of heart disease and stroke in Western countries. Oral treatment with a low dose of THC inhibits atherosclerosis progression in an apolipoprotein E knockout mouse model, through pleiotropic immunomodulatory effects on lymphoid and myeloid cells. Thus, THC may be a valuable target for treating atherosclerosis. 139 N-palmitoyl-ethanolamine is an endogenous endocannabinoid-like compound. Its concentrations are significantly increased in three different inflammatory and neuropathic conditions. The enhanced levels may possibly be related to a protective local anti-inflammatory and analgesic action. 140 CBD has been shown to exert potent anti-inflammatory and antioxidant effects. High-glucose-induced mitochondrial superoxide generation, NF-kappaB activation, nitrotyrosine formation, iNOS and adhesion molecules ICAM-1 and VCAM-1 expression, monocyte-endothelial adhesion, transendothelial migration of monocytes, and disruption of endothelial barrier function in human coronary artery endothelial cells (HCAECs) were attenuated by CBD pretreatment. 141

In experiments with obese vs lean rats, rimonabant was found to be a potent inhibitor of sensory hypersensitivity associated with CFA-induced arthritis in obese rats, in which the inflammatory reaction is more severe than in lean rats. It may thus have therapeutic potential in obesity-associated inflammatory diseases. 142

Parkinson’s disease, Huntington’s disease, Tourette’s syndrome, Alzheimer’s disease, epilepsy

Parkinson’s disease (PD) is a chronic, progressive neurodegenerative disorder. The main pathological feature of PD is the degeneration of dopamine (DA)-containing neurons of the substantia nigra, which leads to severe DAergic denervation of the striatum. The irreversible loss of the DA-mediated control of striatal function leads to the typical motor symptoms observed in PD, ie, bradykinesia, tremor, and rigidity. It has been proposed that cannabinoids may have some beneficial effects in the treatment of PD. 129 In animal experiments cannabinoids provide neuroprotection against 6-hydroxydopamine toxicity in vivo and in vitro. 131

The majority of PD patients undergoing levodopa therapy develop disabling motor complications (dyskinesias) within 10 years of treatment. Recent studies in animal models and in the clinic suggest that CB1 receptor antagonists could prove useful in the treatment of both parkinsonian symptoms and levodopa-induced dyskinesia, whereas CB1 receptor agonists could have value in reducing levodopa-induced dyskinesia. 143 In the reserpinetreated rat model of PD, the dopamine D2 receptor agonist quinpirole caused a significant alleviation of the akinesia. This effect was significantly reduced by coinjection with the cannabinoid receptor agonist WIN 55,212-2. The simultaneous administration of the CB1 antagonist rimonabant with quinpirole and WIN 55,212-2 blocked the effect of WIN 55,212-2 on quinpirole-induced alleviation of akinesia. 144 In animal experiments, chronic levodopa produced increasingly severe orolingual involuntary movements which were attenuated by WIN 55,212-2. This effect was also reversed by rimonabant. 145 In other studies, rimonabant was found to possess some beneficial effects on motor inhibition typical of PD, at least in some doses. The injection of 0.1 mg/kg of rimonabant partially attenuated the hypokinesia shown by PD animals with no effects in control rats, whereas higher doses (0.5-1.0 mg/kg) were not effective. 146 A nigrostriatal lesion by MPTP is associated with an increase in CB1 receptors in the basal ganglia in humans and nonhuman primates; this increase could be reversed by chronic levodopa therapy, which suggests that CB1 receptor blockade might be useful as an adjuvant for the treatment of parkinsonian motor symptoms. 147 High endogenous cannabinoid levels are found in the cerebrospinal fluid of untreated PD patients. 148 Administration of inhibitors of endocannabinoid degradation reduced parkinsonian motor deficits in vivo. 149 Thus, both agonists and antagonists of CB receptors seem to help in some parkinsonian symptoms. In clinical trials, the cannabinoid receptor agonist nabilone significantly reduced levodopainduced dyskinesia in PD. 150 THC improved motor control in a patient with musician’s dystonia. 151 In contrast to these findings, some studies find no effect of cannabinoids on PD: orally administered cannabis extract resulted in no objective or subjective improvement in either dyskinesias or parkinsonism, 152 no significant reduction in dystonia following treatment with nabilone, 153 and rimonabant could not improve parkinsonian motor disability 154 However, an anonymous questionnaire sent to all patients attending the Prague Movement Disorder Centre revealed that 25 % of the respondents had taken cannabis and 45.9 % of these described some form of benefit. 155 Thus cannabinoids seem to be able to treat at least some symptoms of neurological diseases. 156-158

Huntington’s disease (HD) or Huntington’s chorea (“chorea” meaning “dance” in Greek) is a disorder characterized by a distinctive choretic movement, progressive motor disturbances, dementia, and other cognitive deficits. Neuropathologically, HD is characterized by a degeneration of medium spiny striato-efferent γ-aminobutyric acid (GABA)ergic neurons and by an atrophy of the caudate nucleus. Advanced grades of HD showed an almost total loss of CB1 receptors and a further depletion of Dl receptors in the caudate nucleus, putamen, and globus pallidus internus, and an increase in GABAA receptor binding in the globus pallidus internus. 159,160 Loss of cannabinoid receptors is also seen in the substantia nigra in HD. 161 These findings suggest a possible therapeutic role of cannabinoid agonists in HD. Indeed, arvanil, a hybrid endocannabinoid and vanilloid compound, behaves as an antihyperkinetic agent in a rat model of HD generated by bilateral intrastriatal application of 3-nitropropionic acid (3-NP). 162 The reduction in the increased ambulation exhibited by 3NP-lesioned rats in the open-field test caused by AM404 (anandamide’s transport inhibitor, which also binds to vanilloid receptor 1) was reversed when the animals had been pretreated with capsazepine (VR1 antagonist), but not with SR141716A, thus suggesting a major role of VR1 receptors in the antihyperkinetic effects of AM404. However, both capsaicin (VR1 agonist) and CP55,940 (an CB1 agonist) had antihyperkinetic activity 163 Quinolinic acid (QA) is an excitotoxin which, when injected into the rat striatum, reproduces many features of HD by stimulating glutamate outflow. Perfusion with WIN 55,212-2 significantly and dose-dependently prevented the increase in extracellular glutamate induced by QA. Thus, the stimulation of CB1 receptors might lead to neuroprotective effects against excitotoxic striatal toxicity. 164 In a clinical trial CBD was neither symptomatically effective nor toxic in neuroleptic-free HD patients. 165

Tourette syndrome (TS) is a complex inherited disorder of unknown etiology, characterized by multiple motor and vocal tics. Anecdotal reports have suggested that the use of cannabis might improve tics and behavioral problems in patients with TS. Indeed, THC reduced tics in TS patients, 166 without causing acute and/or long-term cognitive deficits. 167 In another clinical trial, where tic severity was assessed using a self-rating scale and examiner ratings, patients also rated the severity of associated behavioral disorders. There was a significant improvement of motor tics, vocal tics and obsessive-compulsive behavior after treatment with THC. There was a significant correlation between tic improvement and maximum 11-OH-THC plasma concentration, suggesting a possible role of this THC metabolite on the positive effect of THC. 168 In another, longer clinical trial, THC was also found to be effective and safe in the treatment of tics. 169 In view of the positive effect of CB1 agonists in the treatment of TS, CB1 gene mutations were investigated. However, TS was not found to be caused by mutations in the CNR1 gene. 170

Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disorder characterized by a selective loss of motor neurons in the spinal cord, brain stem, and motor cortex. Many effects of marijuana may be applicable to the management of ALS. These include analgesia, muscle relaxation, bronchodilation, saliva reduction, appetite stimulation, and sleep induction. In addition, its strong antioxidative and neuroprotective effects may prolong neuronal cell survival. 171 Indeed, treatment of postsymptomatic, 90-day-old SOD1G93A mice (a model of ALS) with WIN 55,212-2, significantly delayed disease progression. Furthermore, genetic ablation of the FAAH enzyme, which results in raised levels of the endocannabinoid anandamide, prevented the appearance of disease signs in these mice. Surprisingly, elevation of cannabinoid levels with either WIN 55,212-2 or FAAH ablation had no effect on life span. Ablation of the CB1 receptor, in contrast, had no effect on disease onset in these mice, but significantly extended life span. Together these results show that cannabinoids have significant neuroprotective effects in this model of ALS, and suggest that these beneficial effects may be mediated by nonCB1 receptor mechanisms. 172 THC was also found to delay the progression of disease. 173,174 Treatment with AM1241, a CB2-selective agonist, was effective at slowing signs of disease progression, when administered after onset of signs in an ALS mouse model. Administration at the onset of tremors delayed motor impairment in treated mice when compared with vehicle controls 175 ; moreover, AM-1241 prolonged survival in these mice. 176 In a survey among ALS patients, cannabis was reported to be moderately effective in reducing symptoms of appetite loss, depression, pain, spasticity, and drooling. 177 Cannabinoids were also proposed to have a role in the treatment of Alzheimer’s disease (AD). THC competitively inhibits acetylcholinesterase (AChE) and prevents AChE-induced amyloid beta-peptide (Abeta) aggregation, the key pathological marker of AD. 178 THC treatment also decreased severity of disturbed behavior, and this effect persisted during the placebo period in patients who had received THC. 179 Compared with baseline, THC led to a reduction in nocturnal motor activity These findings were corroborated by improvements in the Neuropsychiatrie Inventory total score, as well as in subscores for agitation, aberrant motor, and nighttime behaviors; no side effects were observed. 180

Studies on cannabinoid anticonvulsant activity began in 1975, when CBD, and four CBD derivatives, (CBD-aldehyde-diacetate, 6-oxo-CBD-diacetate, 6-hydroxy-CBD-tri-acetate and 9-hydroxy-CBD-triacetate) were shown to protect against maximal electroshock convulsions in mice, to potentiate pentobarbital sleeping-time and to reduce spontaneous motor activity. 181 Later additional CBD analogs were shown to be active 182-184 CBD was found to be an effective anticonvulsant with specificity more comparable to drugs clinically effective in major, but not in minor seizures. Furthermore, it appears that CBD enhances the anticonvulsant effects of drugs in major seizures and reduces their effects in minor seizures. 185,186 Hence, CBD was suggested as a drug for the treatment of children with pharmacoresistant epilepsy. 187 The application of the CB1 receptor antagonists SR141716A or AM251 to “epileptic” neurons caused the development of continuous epileptiform activity, resembling electrographic status epilepticus. The induction of status epilepticus-like activity by CB1 receptor antagonists was reversible and could be overcome by maximal concentrations of CB1 agonists. 188 Arachidonyl-2′-chloroethylamide (ACEA), a highly selective cannabinoid CB1 receptor agonist, enhances the anticonvulsant action of valproate in a mouse maximal electroshock-induced seizure model. 189 There are currently insufficient data to determine whether occasional or chronic marijuana use influences seizure frequency. 190 In one case report, marijuana smoking was proposed to induce seizures. 191 In another study, patients suffering from secondary generalized epilepsy with temporal focus treated with CBD remained almost free of convulsive crises throughout the experiment; other patients demonstrated partial improvement in their clinical condition. 192

Bipolar disorder, schizophrenia, post-traumatic stress disorder (PTSD), depression, anxiety, insomnia

Cannabis use is common in patients with bipolar disorder, and anecdotal reports suggest that some patients use marijuana to alleviate symptoms of both mania and depression. 193 In a case report, one female patient found that cannabis curbed her manic rages; others described the use of cannabis as a supplement to lithium (allowing reduced consumption) or for relief of lithium’s side effects. 194

The effect of cannabinoids on schizophrenia is controversial. Neuropsychological results in THC-intoxicated normal volunteers exhibit strong similarities with data acquired from patients suffering from productive schizophrenic psychoses, as regards disturbances in internal regulation of perceptual processes. 195 In a recent study, it was found that anandamide levels are enhanced in firstepisode schizophrenic patients, and that THC downregulates anandamide signaling. 196 This observation possibly means that THC lowers endogenous production of anandamide, which may actually be a defense mechanism – presumably comparable to the known observation that administration of corticosteroids blocks corticosteroid synthesis. Data from experimental-psychological tests show that personality changes generated by schizophrenia progression are comparable to psychopathological phenomenon due to cannabis intoxication. 197 In another study, psychosis, which develops or recurs in the context of cannabis use, did not have a characteristic psychopathology or mode of onset. 198 First-episode schizophrenic patients with long-term cannabis consumption were significantly younger at disease onset, mostly male, and suffered more often from paranoid schizophrenia (with a better prognosis) than those without cannabis consumption. 199 However, a trend towards more insight and of fewer abusive or accusatory hallucinations was seen amongst cannabis users. This argues against a distinct schizophrenia-like psychosis caused by cannabis. 200 Less avolition and fewer apathy symptoms were detected in patients with schizophrenia and cannabis abuse than in those with no abuse. 201 In another clinical trial, the role of CB1 receptors in schizophrenia was studied by administration of CB1 antagonist to patients. The group receiving the CB1 antagonist did not differ from the group receiving placebo on any outcome measure. 202

CBD causes antipsychotic effects. 203 It was found to be a safe and well-tolerated alternative treatment for schizophrenia. 204 (See, however, also ref 205).

Posttraumatic stress disorder (PTSD) is a term for severe psychological consequences of exposure to, or confrontation with, stressful, highly traumatic events. Cannabinoids are believed to help in such cases. AM404-treated animals showed decreased shock-induced reinstatement of fear. 206 In conditioned fear and Morris water maze experiments, FAAH (-/-) mice and mice treated with the FAAH inhibitor OL-135 did not display any memory impairment or motor disruption, but did exhibit a significant increase in the rate of extinction. SRI 41716 blocked the effects of OL-135, suggesting that endogenous anandamide plays a facilitator role in extinction through a CB1 receptor mechanism of action. In contrast, THC failed to affect extinction rates, suggesting that FAAH is a more effective target facilitating extinction than a direct-acting CB1 receptor agonist. 207 Acutely, the absence of CB1 receptors reduces the neuroendocrine response and does not affect the behavioral response to moderate stress. However, upon repeated stress or acute severe stress, CB1 receptor deficiency causes persistent behavioral inhibition. Repeated bell stress seemed to cause a cumulative fear in CB1 receptor knockout mice. 208 In self-reports of substance use among help-seeking veterans, PTSD diagnosis was significantly associated with marijuana use. 209 These observations suggest that the endocannabinoid system can be modulated to enhance emotional learning, and that endocannabinoid modulators may be therapeutically useful as adjuncts for exposure-based psychotherapies, such as those used to treat PTSD and other anxiety disorders. CB1 receptor gene polymorphism is known to modify transcription of the gene. In patients with Parkinson’s disease, the presence of two long alleles, with more than 16 repeated AAT trinucleotides in the CNR1 gene, was associated with a reduced prevalence of depression. 210

CBD, and some derivatives, were found to cause a selective anxiolytic effect in the elevated plus-maze, within a limited range of doses. 211,212 A single dose of nabilone produced only mild improvement in anxiety 213 ; in a repeated-dose treatment a dramatic improvement in anxiety was noted in the nabilone group. 214

The effects of marijuana on human sleep patterns were noticed long ago. 215-217 Reduced eye movement density was seen, with some tolerance developing to this effect. 218,219 THC is sedative, while CBD has alerting properties as it increased awake activity and counteracted the residual sedative activity of THC. 220

Asthma, cardiovascular disorders, glaucoma

Asthma is a chronic disease of the respiratory system in which the airway occasionally constricts, becomes inflamed, and is lined with excessive amounts of mucus. In animal experiments, after methacholine-induced or exercise-induced bronchospasm, marijuana caused a prompt improvement of the bronchospasm and associated hyperinflation. 221 In humans, habitual smoking of marijuana may cause mild, but significant, functional lung impairment 222 ; However, a mild and inconstant bronchodilatory action was found for THC. 223 In other clinical trials, smoking marijuana or ingesting THC were found to increase airway conduction. 224,225 Other plant cannabinoids did not provide effective bronchodilation. The daily use of THC was not associated with clinical tolerance. 226 THC administered in metered volumes by inhalation from an aerosol device to patients judged to be in a steady state, increased peak expiratory flow rate (PEFR) and forced expiratory volume in 1 second (FEV1) and produced bronchodilatation. 227 In another study, salbutamol and THC significantly improved ventilatory function. Maximal bronchodilatation was achieved more rapidly with salbutamol, but at 1 hour both drugs were equally effective. No cardiovascular or mood disturbance was detected, and plasma total cannabinoids at 15 minutes were not detected by radioimmunoassay. The mode of action of THC differed from that of sympathomimetic drugs. 228

In another study, THC induced sympathetic stimulation and parasympathetic inhibition of cardiovascular control pathways. The peak heart rate rise after THC was attenuated by atropine and by propranolol, and nearly abolished by atropine-propranolol pretreatment. 229 Acute THC significantly increased heart rate, shortened pre-ejection period (PEP) and prolonged left ventricular ejection time (LVETc) without any change in afterload; it enhanced cardiac performance. Partial inhibition of this effect was achieved with prior (β-adrenergic blockade. 230 In contrast, following the smoking of one to three marijuana cigarettes, the heart rate rose, cardiac output rose, stroke volume, ejection fraction, PEP and LVET did not change; thus, in long-term heavy users of cannabis, marijuana has no significant effect on myocardial contractility independent of its effect on heart rate. 231 Cardiovascular effects of acute THC administration included increased sympathetic and reduced parasympathetic tone; supine tachycardia and increased blood pressure with upright hypotension were observed. With repetitive dosing supine bradycardia and decreased blood pressure with tolerance to orthostatic hypotension were observed. 232,233 Rimonabant attenuated the hypotensive effect of smoked marijuana in male smokers, suggesting a role for the CB1 receptor in cannabinoid hypotensive action. 234

A number of studies suggest that there is a correlative, but not necessarily causal, relationship between glaucoma and systemic hypertension. Ocular hypertension (OHT) refers to any situation in which intraocular pressure is higher than normal, and is the most important risk factor for glaucoma. THC, CBN, and nabilone were active in lowering intraocular pressure (IOP) in rabbits, while CBD was inactive. 235 Certain derivatives of THC were more active in lowering IOP than the parent cannabinoid 236 ; some topically used soft analogs that have no systemic effects were also active in IOP reduction. 237 The effect on IOP of 2-AG was biphasic (ie, an initial increase in IOP followed by a reduction). In contrast, noladin ether decreased IOP immediately after topical administration, and no initial IOP increase was observed. AM251 blocked the effect on IOP of noladin ether, but did not affect the action of 2-AG. 238 Topical administration of anandamide and arachidonyl propionitrileamide decreased IOP; rimonabant antagonized the IOP reduction, suggesting that cannabinoids lower IOP through CB1 receptors. 239,240 Significantly, higher levels of CB1 mRNA levels were found in the ciliary body than in the iris, retina, and choroid. CB2 mRNA was undetectable. This expression pattern supports a specific role for the CB1 receptor in controlling IOP. 241 When delivered topically to cat eyes with osmotic minipumps, whole marijuana extract, THC and other plant cannabinoids reduced IOP, while cannabichromene was inactive. Ocular toxicity was seen after THC treatment, consisting of conjunctival erythema and chemosis as well as corneal opacification. Although these changes also occurred with marijuana extract, their intensity was much reduced. In contrast, no ocular toxicity was apparent during administration of plant cannabinoids other than THC. 242-244 Marijuana smoking was shown to reduce IOP as early as 1971; the effect was later confirmed. 245-248 The peak effect of THC on the central nervous system coincided well with the reduction in intraocular pressure induced by the drug; However, hypotonia outlasted euphoria. The results indicate that THC may have value as a hypotonizing ocular drug. 249 The functional responses after THC inhalation in sitting normotensive and hypertensive patients included invariable increases in heart rate followed by substantial decreases in systolic pressure, diastolic pressure, and intraocular pressure. The intensity and duration of the arterial and ocular pressure responses to THC were greater in hypertensives than in normotensive patients; the changes in ocular pressure paralleled the changes in blood pressure in glaucoma patients. 250 A single sublingual dose of THC, but not cannabidiol, reduced the IOP temporarily and was well tolerated by most patients. 251


The antiproliferative action of cannabinoids on cancer cells was first noticed in the 1970s. Since then cannabinoids were found to act on various cancer cell lines, through various mechanisms. 252,253 Cannabinoids were also found to be suppressors of angiogenesis and tumor invasion. 254 Our knowledge on the anticancer activity of cannabinoids is rapidly expanding; hence only results of recent research on this topic are presented here. The cannabinoid agonists HU-210 and JWH-133 promoted glial differentiation in a CB receptor-dependent manner. Moreover, cannabinoid challenge decreased the efficiency of glioma stem-like cells to initiate glioma formation in vivo. 255 The nonpsychoactive cannabidiol triggered caspase activation and oxidative stress in human glioma cells. 256 Human melanomas express CB1 and CB2 cannabinoid receptors. Activation of these receptors decreased growth, proliferation, angiogenesis, and metastasis, and increased apoptosis, of melanomas in mice. 257 THC, through activation of CB2 cannabinoid receptors, reduced human breast cancer cell proliferation by blocking the progression of the cell cycle and by inducing apoptosis. THC arrested cells in G2M via downregulation of Cdc2. 258 Cannabinoids induced apoptosis of pancreatic tumor cells via stress protein p8 and endoplasmic reticulum stress-related genes. These effects were prevented by blockade of the CB2 cannabinoid receptor or by pharmacologic inhibition of ceramide synthesis de novo. 259 THC-induced apoptosis in Jurkat leukemia T cells was found to be regulated by translocation of Bad to mitochondria. 260 Exposure of leukemia cells to CBD led to CB2-mediated reduction in cell viability and induction in apoptosis (although CBD is considered not to bind to either CB1 or CB2 receptors). It is noteworthy that CBD exposure led to an increase in reactive oxygen species (ROS) production as well as an increase in the expression of the NAD(P)H oxidases Nox4 and p22(phox). 261 Cannabinoid-induced apoptosis of human prostate cancer cells LNCaP proceeded through sustained activation of ERK1/2 leading to Gl cell cycle arrest. 262 Rimonabant inhibited human breast cancer cell proliferation through a lipid raft-mediated mechanism. 263 In a pilot phase I trial, nine patients with recurrent glioblastoma multiforme, that had previously failed standard therapy (surgery and radiotherapy) and had clear evidence of tumour progression, were administered THC intratumorally. THC inhibited tumor-cell proliferation in vitro, decreased tumor-cell Ki67 immunostaining and prolonged the survival time of two of the patients. 264


Many drugs used today can cause addiction and are misused and abused, for example opiates, 265 cocaine, 266 benzodiazepines, 267 barbiturates, 268 cholinergic agonists, 269 ketamine, 270,271 dopaminergic agonists, 272 amphetamines, 273 and others. Nevertheless they are still an important part of our pharmacopeia. Marijuana was used for centuries as a medicinal plant, but during the last century, because of its abuse and addictive potential it was taken out of clinical practice. Now, we believe that its constituents and related compounds should be brought back to clinical use. The reasons are: (i) the therapeutic potential of CB1 agonists is huge, as described in this review; (ii) for local action, topical CB1 agonists, or agonists that do not penetrate the blood-brain barrier, can be used; (iii) cannabinoids acting specifically on CB2 receptors, which cause no psychoactivity, may be used on peripheral targets (such as osteoporosis, 274,275 which is only one of many examples); (iv) there are additional, new cannabinoid targets distinct from the CB1/CB2 receptors 276-278 which do not cause psychoactivity; (v) there are cannabinoids, such as CBD, which do not cause psychoactivity, but have various therapeutic effects.

The endocannabinoid system is a very complex one and regulates numerous processes, in parallel with other wellknown systems, such as the adrenergic, cholinergic, and dopaminergic systems. Neglecting the potential clinical uses of such a system is, in our view, unacceptable; instead we need to work on more selective agonists/antagonists, more selective distribution patterns, and in cases where it is impossible to separate between the desired clinical action and the psychoactivity, to monitor these side effects carefully.