Cannabis, like many medications including common ones like SSRIs, benzodiazepines, opioids, and others, can cause dependence.  This sounds like a bad thing, and it can be.  It is often confused with addiction, which is more commonly recognized as something to be avoided.  So, what is dependence really, what is the difference from addiction, what’s really happening in our bodies, and what do we do about it?

Come along and let’s discuss!

What Is Dependence and How Is It Different From Addiction?

First we need to clarify that dependence and addiction are not the same thing.  They often go together and so are often confused. 

Dependence is a physiological process – a change in your body chemistry.  Addiction is a harmful behavioral outcome.  As you can imagine, one can lead to the other, but we don’t always see both occurring.  

The consequence of dependence is that your body gets “used to” a substance and then you get withdrawal symptoms if you stop that substance.  For example, people who stop using an SSRI too abruptly can have rebound depression, cognitive dysfunction (“brain fog”), and sometimes a sensation people describe as “brain zaps”.  

Does this mean we shouldn’t use SSRIs for people with depression?  No, of course not.  A recent large meta-analysis looked at data for SSRI use over the past 15 years and found that SSRIs provided significant benefit to patients with minimum of risk. However, clearly we need to use SSRIs in the right circumstances, for the right patients, and monitor patients’ care closely, including if the patient needs to stop these medications. 

Cannabis is no different.  Use of cannabis can provoke dependence in roughly 7% of users (based on recreational user data and also complicated by higher risk in teens and lower risk in adults).  However, use in careful medical settings can mitigate even this relatively low risk.

Unlike SSRIs, but like many other dependence forming medications, cannabis can also cause addiction.  This is formally called Cannabis Use Disorder (CUD).  Like all Use Disorders (UD), CUD is a set of maladaptive behaviors that develop around the use of a substance.  This happens more when there is little attention paid to dose and frequency of use – as you would see in recreational use more than in medical.  In fact, one of the primary goals of medical use is to monitor the dose and frequency to minimize the risk of both dependence and UD.

What’s Really Going On?

This is how I think of it:  You know those satellite dishes that people put on the sides of their homes instead of cable?  Think of neurotransmitter receptors like those.  The neurons in our brains have many of these satellite dishes on their surface to “hear” messages from other cells that come by neurotransmitter.  The cannabinoid receptors that bind THC are actually there to hear our internal cannabinoids (called Endocannabinoids) which play a vital role in our bodies.

Now imagine that you flood your brain with a large amount of outside cannabinoids, like THC (also called Phytocannabinoids, meaning from plants).  That poor cell is swamped.  It’s like the THC is screaming at it at the top of its lungs!  How does that poor cell survive without going crazy?  It starts to remove some of those satellite dishes – to turn down the volume.  This is called Downregulation. 

In small measure this is fine and often called Tolerance.  However, the line between tolerance and dependence is fine and fuzzy.  If enough dishes come down, there are no longer enough to adequately “hear” the internal cannabinoid signaling.  Then we lose the important messages being sent by those endocannabinoids and we become dependent on the outside phytocannabinoids to stimulate those remaining receptors.  Take those outside cannabinoids away and our cell is lonely and starts to “grumble” and that leads to withdrawal symptoms.

So What Do We Do About It?

A significant goal of medical treatment is to find the sweet spot where we use just enough medicine to treat a problem but not so much that we create another problem like dependence or a UD.  In essence, the medical approach is always “less is more”.

This is an instance of things going better if we do it right the first time.  Careful attention to dose and timing is critical to hitting that sweet spot.  

Unfortunately, dose and timing are not usually considered by folks who use cannabis for recreational purposes, and this can lead to all of the above problems.  Where I see this most is when recreational users get older and develop medical problems that we need to address with cannabis.  High tolerance or dependence can stand in the way of getting the medical benefits.  

Deprived of that excessive flood of outside cannabinoids, the lonely cell will eventually, over a number of weeks, put back those satellite dishes and will again be able to hear the endocannabinoids.  However, if we do this withdrawal abruptly, it’s unpleasant.  

Gentle weaning is a better approach. I often do this with patients who have already developed excessive tolerance or dependence to improve medical benefit, but it requires a lot more effort and attention.  

I strongly recommend a careful medical approach so we hit that sweet spot and preempt any problems.  Know that there are ways to deal with these problems as well if you find you’re already there. 

Consult with a Qualified Boston Medical Marijuana Expert Today 

Those considering using THC, CBD, or any type of medicine found in cannabis to help manage their condition should consider speaking to a trained medical expert who is knowledgeable about using cannabis therapeutically. Massachusetts medical marijuana doctor Jordan Tishler, M.D. sits on the faculty of Harvard Medical School and has years of experience helping patients treat pain and other ailments using cannabis. He and the team at InhaleMD stand ready to assist patients in determining whether medical marijuana is right for them. For more information, or to set up a virtual consultation with the team at InhaleMD, call us at (617) 477-8886 today.

Photo credit to: Sandra Cohen-Rose and Colin Rose

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