Accurate Education – Cannabis Use Disorder

The overall prevalence of patients reporting cannabis use that met criteria for any CUD (including mild CUD) was 21.3% and did not vary across the three groups. However, the prevalence of those who met criteria for moderate to severe CUD was 6.5% overall, but did differ across groups: only 1.3% for medical use, but 7.2% for nonmedical use, and 7.5% who reported both reasons for use. In essence, for those who reported nonmedical use the prevalence was significantly higher than for those who reported medical use only.

Cannabidiol (CBD) is the second most abundant cannabinoid found in most marijuana strains and is known to be safe and well tolerated with few adverse effects. CBD has minimal direct action at cannabinoid receptors but it has multiple pharmacologic actions including inhibiting the breakdown and reuptake of endocannabinoids and modulation of cannabinoid receptors. CBD has been shown to reduce cannabis withdrawal symptoms during cannabis abstinence and is associated with improvements in psychological well-being and thought processing in cannabis users.

CBD’s impact on the reinforcing effect of cannabis.

Preliminary data also suggests a possible beneficial effect of CBD on the reinforcing effect of cannabis. In a study that evaluated the impact of varying levels of CBD and THC (low or high CBD:THC ratios) on the acute effects of cannabis intoxication, no difference in either group was found in their rating of feeling “stoned.” However,  a high CBD:THC ratio was associated with lower ratings of pleasantness , or “liking.”

CBD’s impact on relapse risk of caannabis

CBD has therapeutic potential relevant for multiple conditions that underlie relapse risk, including craving induced by drug-related environmental contexts, susceptibility to stress, heightened anxiety and, possibly, impaired impulse control.

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CBD’s impact of drug-related cues

CBD has shown therapeutic benefits in human and preclinical models of addiction by reducing the impact of drug-related cues in attentional bias, cue-induced craving and cue-induced reinstatement paradigms. Collectively, multiple studies indicate that CBD may have potential for treating a range of substance use disorders including cannabis, opioids, tobacco and alcohol (See: CBD – Treatment of Addiction).  

CBD case reports and controlled trials

In 2015, a case report was published reviewing the use of cannabidiol (CBD) oil to decrease the addictive use of marijuana and provide anxiolytic and sleep benefits. The dosage gradually decreasing from 24 to 18 mg CBD/day. The patient reported being less anxious with an improved, regular pattern of sleep. He also indicated that he had not used any marijuana since starting the CBD oil. With the decrease in the dosage to 18 mg, the patient was able to maintain his abstinence of marijuana.

Another case report evaluated the effects of CBD on the last phases of addiction, which showed benefits for the withdrawal phase and perhaps even for the relapse phase.  In this report, a 19-year-old female with cannabis dependence who experienced withdrawal syndrome when she tried to stop cannabis use, CBD was administered for 11 days (300 mg on day 1, 600 mg on days 2–10, and 300 mg on day 11). Daily assessments showed a rapid decrease in withdrawal symptoms, with resolution of symptoms by day 6.  A 6-month follow-up showed a relapse in cannabis use, but at a lower frequency (one or twice a week vs. 7 days a week).

The first randomized, double blind, placebo controlled trial evaluating CBD (isolate, without terpenes) for treatment of CUD was published in 2020. Participants were initially randomised to four-week treatment with oral 200 mg, 400 mg and 800 mg CBD doses daily or placebo. The 200 mg CBD dose was discontinued early in the trial as being ineffective. At final analysis, both 400 mg and 800 mg daily doses of CBD were determined to be effective and well tolerated with no severe adverse events and 94% of participants completed treatment. Not only did participants demonstrate significantly reduced relapse rates for cannabis use but withdrawal and anxiety symptoms were also reduced and sleep was improved.

 Additional Considerations

1. When taking CBD to treat CUD, additional treatment options should be considered. First, if there is an underlying chronic pain condition, anxiety or sleep concerns the choice of CBD product should include a broad spectrum profile of terpenes pertinent to the secondary conditions requiring treatment. Furthermore, the inclusion of the CB2 agonist terpene, β-caryophyllene, with the CBD should be considered.

Research suggests that CB2 receptors play a major role in alcohol reward and the CB2 receptor system may be involved in alcohol and cocaine dependence via modulation of dopamine reward pathways. In mice, β-caryophyllene has been shown to reduce voluntary alcohol intake as well as decrease cocaine self-administration. It may therefore represent a potential pharmacological target for the treatment of alcohol and cocaine abuse and by extension may offer benefit for THC abuse.

2. While existing research appears to be limited to oral treatment with CBD only, consideration should be given to sublingual administration of the CBD or inhalation, preferably vaping. The advantage of these methods allows for greater bioavailability and more rapid onset of effect that may be more effective in quelching cravings.  Additionally, with inhalation, engaging the familiar ritual of smoking or vaping that is associated with the cannabis use would also be expected to reduce cravings.