Cannabis Patient Care - December 2022

Cannabis Patient Care- December 2022

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9 doctor focus november/december 2022 | cannabis patient care Fur thermore, cannabis is safer than many anxiety drugs, especially those in the benzodiazepine class (such as Xanax or Valium) which, with long-term use, can cause depend- ence, neurotoxicity, cognitive and memor y problems, and more. Patients are often successful replacing these danger- ous anxiety medications with cannabis, and are motivated to do so because cannabis works better and has fewer side effects. One study found that 45% of benzodiazepine users stopped the drugs completely after star ting medical canna- bis (6). Another sur vey of 1513 dispensar y members revealed that 71.8% of respondents reduced their intake of anti-anxie- ty medications (7). A Double-Edged Sword The use of tetrahydrocannabinol (THC)-dominant cannabis has been associated with both anti-anxiety effects at lower doses and anxiety-causing effects at higher doses (8). Clearly, THC overdose often produces severe anxiety and paranoia; even though people often are certain they're dying and require emergency medical care, that's rarely the case. For most people, there's a wide range between a relaxing dose and an anxiety-producing dose. Cannabis users who ingest drops, edibles, or capsules might have to consume 2-3 times their normal anti-anxiety dose or more to experience this paradoxical effect. Inhaled cannabis can be a little touchier for some people with anxiety. The rapid onset of anti-anxiety relief after smoking or vaporizing makes this an appealing route of administration, but small differenc- es in the type of cannabis being inhaled or the total dose can swing some sensitive individuals into worse anxiety. I've spoken with several patients who experience this side effect and think the best strategy is just to "deal with it." They inhale cannabis, feel more anxious for 10-30 minutes, then ap- preciate the anti-anxiety effects in the following 1-3 hours. At the end of the article I provide practical solutions for people who can relate to this; most are able to modify their use pat- tern to achieve all relief and no exacerbation of symptoms. While the bidirectional dose-response effect on anxiety may be most evident for THC-dominant cannabis, pharmaceu- tical-grade cannabidiol (CBD) has also demonstrated similar dose–response trends (9). For example, in one study of healthy subjects, a 300-mg dose of CBD was associated with improve- ments in anxiety scores compared to placebo during public speaking, while a 900-mg dose was associated with increased anxiety scores compared to placebo (10). These doses are not practical or necessary for most people; the more standard range of CBD dosing for anxiety, 10–50 mg up to 3x daily, is like- ly to help reduce and unlikely to increase anxiety. Fear-Extinction As mentioned above, the ability to unlearn, or extinguish, fear- ful memories and their associated responses is an important part of the healing process in trauma-related disorders. This type of healing is often the goal of several non-pharmaco- logical treatments like eye movement desensitization and reprocessing (EMDR), prolonged exposure therapy, cognitive and behavioral therapy (CBT), and emotional freedom tech- nique. Several experimental human studies have indicated that cannabinoids can also be helpful in fear extinction, potentially improving the benefits of some of these other types of therapy when used together. For example, a single 7.5-mg dose of THC administered 2 hours before fear extinction treatment, compared to placebo, resulted in significantly decreased threat responses 1 day and 1 week later, accompanied with functional brain imaging data showing a significant effect on the connectivity of threat-de- tection networks (11). Another study found that 32 mg of in- haled CBD enhanced consolidation of fear extinction learning in humans (12). Both suggest that cannabinoids may have po- tential as an adjunct to extinction-based therapies for anxiety and trauma disorders. Another study found that among 136 individuals receiv- ing cannabitriol (CBT) for co-occurring PTSD and substance use disorders, higher cannabis use was associated with great- er PTSD symptom severity early in treatment but lower PTSD symptom severity later in treatment. The authors suggested that cannabis may have interacted synergistically with psy- chological treatment to reduce PTSD symptoms (13). It's important to remember that for those of us with anxie- ty and trauma-related symptoms, life is therapy, or at least it Usually, cannabis will relieve anxiety and trauma-related symptoms, but sometimes it can bring traumatic feelings or memories to the surface for the purpose of healing. I've provided a framework for understanding this phenomenon and suggestions for how to get great results using cannabis for both symptom relief and healing. -DR. DUSTIN SULAK

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