Cannabis is currently undergoing a massive re-brand; the image of the high school stoner furtively smoking a fat spliff has been replaced by a young urban professional vaping a specialty strain from a chic dispensary. But what can this supposed wonder drug do outside the sphere of recreation? Could medical cannabis be used to treat like substance use disorder?
We spoke with Dr. Patricia Frye, a physician with a background in pediatrics and anesthesiology, and an expert in the areas of endogenous and exogenous cannabinoid physiology, about the entourage effects of phytocannabinoids and terpenoids and their role in treating chronic and debilitating conditions.
How exactly does cannabis work in helping to treat addiction?
Cannabinoid receptors in the brain crosstalk with opioid receptors. This not only reduces cravings for patients with pain but also increases the pain-relieving effect of the opioid without increasing the risk of respiratory depression. After adding cannabis, patients can reduce their opioid dose 50-75% and experience the same, if not better, pain relief. Cannabis can also mitigate many of the symptoms caused by withdrawal, like nausea and vomiting, muscle spasm, insomnia, pain, and anxiety.
Is it effective in treating substance use disorders across the board; for instance, is it as effective in treating alcoholism as it is in treating opioid addiction?
Research has found that high doses of CBD can extinguish cravings for opioids, alcohol, nicotine, and benzodiazepines. It does not appear to have that effect on psychostimulants. And again, it relieves the symptoms associated with withdrawal.
Is this replacing one substance with another? Or do you see it differently?
I don’t think people aspire to become addicted to drugs. They are generally trying to feel relief, either from physical or emotional pain. Unfortunately, a lot of the substances that give them that relief are highly addictive and with very narrow safety profiles. Switching to cannabis is replacing a very deadly substance with a non-lethal substance. We replace heroin with methadone, which is highly addictive and has significant adverse effects. If patients use balanced varieties with both CBD and THC, they benefit by feeling better and being unimpaired. For those who find respite with cannabis intoxication, if they make a mistake and take too much, it might make them sick, but they won’t stop breathing and die.
If people are interested in treating their substance use disorder with cannabis, where do you recommend they start? Are there particular strains you recommend or avoid?
I highly recommend starting with an experienced and supportive health care provider and not trying to do it alone. Some substances have to be weaned very slowly, requiring medical supervision, and patients often need other types of emotional support while adjusting to healthier lifestyle habits.
For use disorder, CBD-dominant varieties made into tinctures or tinctures with no THC can be used for under-the-tongue administration. Absorption is through the small blood vessels in the mouth and some through the intestines, so the effects last longer then inhalation. If there is THC, this allows it to cross the blood-brain-barrier more slowly, allowing for reduced activation of the reward centres in the brain that promote misuse. Inhaling high-THC varieties is not advised for patients with use disorder.
Single large doses of CBD can extinguish cravings for opioids, alcohol, nicotine, and benzodiazepines for up to a week. Pain patients who are physically addicted and are using opioids as prescribed can also be treated with CBD:THC ratios and dosing that is adequate for pain relief. I recommend tinctures for longer lasting effects and inhalation only for severe pain or if the patient is unable to achieve adequate pain relief with a tincture or “medible” like a gummie or lozenge.
Cannabis varieties with relaxing terpenes like myrcene and linalool may be better for use disorder, whereas those higher in limonene and beta-caryophyllene can be very effective for relieving pain. It’s difficult to pinpoint specific varieties because varieties, even with the same name, vary significantly in cannabinoid and terpene profiles and effect, and everyone has a unique endocannabinid system and responds to cannabis differently.
Have you encountered anyone in your line of work who has effectively treated their substance use disorder with cannabis?
Most of my patients have chronic pain and have a physical addiction to opioids. They have been able to transition from opioids to cannabis with very good pain control and minimal effects from withdrawal. One patient with a spinal cord injury and severe neuropathic pain and muscle spasm was taking 1500mg of methadone per month and 40mg of oxycodone per day plus several other medications and was still having significant pain as well as depression and anxiety. With cannabis he was able to reduce his methadone dose to 100mg per month and oxycodone to 5mg about twice per week within a year. At two years he had completely discontinued both the methadone and oxycodone, with much improved pain relief and feeling better emotionally as well.
I have only a couple of patients with histories of heroin or crack cocaine addiction. They are both doing well and working. Their sobriety has been maintained with daily use of cannabis with balanced ratios of CBD and THC for daytime and some THC at night for relaxation and sleep.
Dr. Patricia Frye is the Chief Medical Officer of HelloMD, the world’s largest online community of board certified, licensed cannabis doctors, researchers and educators, patients, and consumers. She is also an independent physician consultant with a focus on cannabis and the role it plays in homeostasis and the management of pain and chronic disease. She is currently evaluating and managing patients who are seeking medicinal cannabis as a primary or adjunct therapy for illnesses such as chronic pain syndromes, neurodegenerative disorders, gastrointestinal disease, seizures, autoimmune diseases, insomnia, cancer, anorexia, and mood disorders.