According to the Anxiety and Depression Association of America, anxiety disorders are the most prevalent mental illnesses in the United States, affecting 18.1% of Americans every year. Although anxiety disorders are considered highly treatable, survey data show that only about 37% of those suffering from them receive treatment. This may be due to misdiagnosed or undiagnosed anxiety, a lack of access to health care services, or a dislike for traditional therapies.
Cannabis’s medical use in the treatment of anxiety disorders has piqued the attention of researchers, health care professionals, and patients alike, and studies suggest that cannabis may help many individuals. As more states legalize marijuana for medicinal purposes while others reconsider their medical use guidelines, anxiety is becoming increasingly prominent on their lists of acceptable ailments. This is currently feasible because of the study of the endocannabinoid system (ECS) and its function in homeostasis. While there are no precise dosing or timing instructions, clinicians employ cannabis as a first-line and add-on therapy in effective customised anxiety management programs.
Anxiety is a response to perceived danger that involves both the mind and the body. It has a wide range of emotions, from mild unease to terror, as well as physical symptoms ranging from an increased heart rate to fleeing from a hazard. When the emotional reaction is excessive in duration, frequency, or intensity compared to the cause, it is considered abnormal.2 The ICD-10 definition of generalized anxiety disorder (GAD) (code F41.1) begins with the statement that it is “a disease characterized by excessive worry and dread, and feelings of uneasiness lasting six months or longer.” However, anyone who has suffered from anxiety will tell you that it isn’t always this easy. Anxiety symptoms can be intermittent or persistent, and they vary from person to person. Anxiety can wreak havoc on a person’s everyday life if left untreated, causing physical illness symptoms such as abdominal discomfort and headaches, as well as emotional issues including not being able to get out of bed in the morning or limiting social interactions.
Anxiety disorders are classified into a variety of categories, including GAD, panic disorder, social anxiety disorder (SAD), specific phobias, obsessive-compulsive disorder, posttraumatic stress disorder (PTSD), major depressive disease, and persistent depressive illness. Regardless of the precise diagnosis, the mental and physical symptoms are similar in nature but differ considerably in intensity and duration. They affect every system in the body.
Nervous System: When the brain detects a hazard, it activates the fight-or-flight mechanism. The brain releases endorphins, cortisol, and other neurotransmitters in order to help the body deal with possible dangers. If they’re constantly exposed to these chemicals, they might induce feelings of dread or doom, attention difficulties, and panic attacks. Long-term exposure to these hormones and neurotransmitters as a result of anxious thoughts is linked to weight gain, sadness, and suicide.
Respiratory System: Panicky breathing is characterized by rapid, shallow breathing, especially during a panic episode.
Circulatory System: Palpitations of the heart are associated with panic attacks, but they can also be caused by general anxiety and may be felt more like a vibration in the chest. When anxiety increases, blood pressure might rise. Hypertension can develop if it isn’t treated promptly.
Immune System: Stress hormones are constantly being released into the body, which damages the immune system and raises the risk of viral and bacterial infections.
Gastrointestinal System: The brain-gut connection is especially apparent in anxiety disorders, as stomach aches, nausea, and diarrhea are often the first symptoms of long-term generalized anxiety. While it was previously thought that irritable bowel syndrome (IBS) was a manifestation of anxiety, scientists now believe that IBS has its own pathology; nonetheless, those who have IBS commonly experience anxiety, which exacerbates gut symptoms.
Musculoskeletal System: Anxiety may cause a variety of uncomfortable symptoms in muscles and joints that do not have an obvious origin.
Treatment Options for Anxiety
Anxiety, like other mental illnesses, can cause significant problems in a person’s life if left untreated. Anxiety may make it difficult to focus, complete job or school tasks, fulfill daily chores, establish or maintain personal relationships, and more. Untreated anxiety has also been linked to more serious ailments such as depression, suicide, and drug/alcohol abuse. It may also be manifested as physical illness if left untreated.
There are a variety of anxiety treatment choices accessible, depending on the symptoms and severity of the condition. Medication (in depth below), therapy, alternative and complementary medicine, and transcranial magnetic stimulation are among the most common therapies used to treat anxiety disorders. Doctors frequently prescribe antidepressants or antianxiety medications in combination with therapy or other complementary treatment when treating anxiety disorders. When choosing a treatment strategy, it’s critical to consider all available treatments, including cannabis.
The most popular and effective anxiety treatment is cognitive behavioral therapy, which focuses on detecting, comprehending, and altering thought and behavior patterns.1 Therapy of any kind necessitates that the patient be engaged in acquiring the skills needed to manage anxiety. While traditional therapy typically includes face-to-face sessions with a therapist, advances in technology now allow patients to engage with therapists by phone, video call, or even text message.
Complementary & Alternative Medicine
There’s a lot of evidence that complementary and alternative medicine approaches can help with anxiety symptoms. Meditation, yoga, and acupuncture are just a few examples of such techniques.
For patients who do not respond to antidepressants and other therapies, repetitive TMS (rTMS) may be a safe, effective, and noninvasive alternative. TMS uses an electromagnetic coil and a magnetic field to create a mild electric current in a specific area of the brain; this is produced by the magnetic field generated by the electromagnetic coil that sends pulses via the scalp. TMS is legal in the United States.
Medication for the Treatment of Anxiety
Antidepressants are one of the most widely used medications for anxiety disorders, and they are generally considered safe and efficient. For short- or long-term treatment, they may be used alone or in combination with other types of therapy. It usually takes time and patience to discover the medication that works best for their condition. According to the 2009–2010 Medical Expenditure Panel Survey, over 16 percent of Americans use a psychiatric medication such as an antidepressant or a sedative.5 It’s critical to know how these drugs work in order to comprehend how cannabis may impact anxiety responses. There are four distinct types of anti-anxiety medications available.
Selective serotonin reuptake inhibitors (citalopram, escitalopram, fluoxetine, paroxetine, and sertraline) work by blocking the reabsorption of serotonin in specific brain cells. Venlafaxine and duloxetine are SNRI antidepressants that function via both a serotonergic and norepinephrine-reuptake pathway. They increase neurotransmitter levels such as serotonin and norepinephrine while also inhibiting their reuptake into neurons. Benzodiazepines (alprazolam, clonazepam, diazepam, and lorazepam) are used to treat short-term anxiety or as an add-on approach for treatment-resistant anxiety disorders. Triptans work by enhancing the action of gamma-aminobutyric acid and have sedative, hypnotic, and anxiolytic (anxiety reducing) effects. Tricyclic antidepressants (imipramine, amitriptyline, and nortriptyline), one of the oldest types of antidepressant medicines that increase norepinephrine and serotonin levels while also preventing acetylcholine from functioning, are effective in the management of panic disorder.
Previously, it was thought that pharmaceuticals were the only chemicals able to alter neurotransmitter and stress hormone production in addition to medicines. However, recent studies on exercise and meditation have shown that they may help reduce the stress response and/or associated symptoms of systemic overload. More significantly, the finding of the ECS revealed new pathways by which the brain can maintain whole-body stability.
The ECS and Anxiety
The ECS was first discovered at the Hebrew University of Jerusalem in 1992. The cannabinoid receptors CB1 and CB2, as well as their ligands anandamide (N-arachidonoylethanolamide) and 2-AG (2-arachidonoylglycerol), are included in this signaling pathway. The ECS, like the human homeostasis system, is a complex system of interconnected organs and tissues that work together to maintain a stable internal environment even in the face of external stressors. The ECS’s involvement in a wide range of biological processes, including energy expenditure, food intake, pain sensation, inflammation, cognition, and stress responses such as anxiety has been proven through study. CB1 receptors are abundantly expressed in the brain areas that manage cognitive and emotional functions (amygdala, prefrontal cortex, and hippocampus), suggesting that the ECS is involved in emotional processing and mood and anxiety management.
CB1 receptors are involved in the firing of serotonin-making neurons, therefore CB1 receptor agonists and AEA hydrolysis-inhibitors boost these neurons’ activity. Anxiety is relieved by increasing serotonergic neurotransmission. 8,9 CB1 receptors have been shown to increase norepinephrine release and activation in the prefrontal cortex via stimulation. 9,10 As a result, phytocannabinoids can aid anxiety management by modulating ECS function similarly to other medicines previously mentioned.
Cannabinoids (including THC and CBD) have been discovered to inhibit the enzyme that destroys AEA, resulting in more AEA and increased serotonin activity, which leads to anxiolytic-like effects. Norepinephrine release has also been confirmed with THC’s activation of CB1 receptors. CBD and THC work together somewhat like an SSRI used to treat anxiety and depression do when they are taken together.
However, animal studies and human evidence indicate that cannabis has a two-pronged impact on anxiety. Phytocannabinoids have anxiolyticlike effects at low dosages, whereas higher dosages result in an exacerbated anxiety (anxiogenic) response.
The Biphasic Nature of Cannabis in the Treatment of Anxiety
The No. 1 reason people choose to use medical marijuana is to relax, yet anxiety is also frequently mentioned as a side effect of cannabis use in medical settings, with panic attacks and paranoia being reported after large dosages of THC intake. When considering the ECS’s role in establishing homeostasis through response matching, it’s no surprise that cannabis can be both anxiogenic and anxiolytic. Low doses generally produce anxiolytic-like effects, while high doses have a sedative effect.
Single molecule, synthetic cannabinoids such as nabilone (synthetic THC analog and CB1 agonist), which has been proven to be efficient in the treatment of anxiety, have received a significant amount of study. The CB1 receptor is thought to play a role in anxiety pathophysiology and its activation appears to beversely correlated to anxiety symptoms. Preclinical studies on GAD suggest that CBD possesses both anxiolytic and antipsychotic properties. Investigations on animals suggest that high doses of CBD (100 mg/kg) are ineffective in treating anxiety symptoms in models of GAD, but low dosages (10 mg/kg) have anxiolytic effects.17 While the bimodal nature of cannabis in the treatment of anxiety is demonstrated by observational research, researchers agree that further study is required to understand the mechanisms of action, which may be complicated.
CBD Oil for Anxiety
In this placebo-controlled trial, participants had altered blood flow in brain regions linked to anxiety symptoms on magnetic resonance imaging (MRIs). CBD not only alleviated symptoms but also affected the way the brains of individuals responded to stress, according to a 2017 study. CBD oil may help with a variety of anxieties, including GAD. 19 In 2015, a review published in Neurotherapeutics claimed that CBD oil has promise as a treatment for various kinds of anxiety, including GAD. However, the number of people studied and dosing as a limitation to present therapy recommendations were both noted as limitations. Most research has been done in acute CBD administration; thus the impact of long-term CBD dosing needs further study before clinical recommendations can be made.
Practice Points for Clinicians
The safety of cannabis, particularly hemp oil, is a concern for many people. According to the state’s health department, there have been no reported cases of poisoning from foods or supplements containing CBD. It should be noted that this does not preclude the possibility of other negative effects. Nonetheless, the CBD:THC ratio, dose, and timing for anxiety treatment are still being investigated by researchers. That said, evidence is growing in favor of cannabis use as a first-line and adjunct therapy for anxiety disorders. The goal of anxiety therapy is to achieve the maximum reduction in symptoms with the lowest tolerable intoxicating effects; therefore personalization is essential.
There are three options for treating anxiety when it comes to cannabis products: high CBD, 1:1 CBD:THC, and CBD only. Because cannabinoid analysis isn’t required in most states where marijuana is legal, finding these in flower or whole plant goods may be difficult. That’s why professional clinicians suggest tinctures and vape concentrates for the treatment of anxiety; these items generally contain clear information about what proportion of the product is CBD, THC, and other cannabinoids. Because first-pass liver metabolism modifies the active metabolites in the body, edibles are not advised. Other concentrates, such as dabs, wax, and shatter, are also more difficult to titrate and generally deliver too much THC for anxiety treatment.
One of the most common questions we get is, “How much CBD oil should I take?” Acute anxiety can be extremely debilitating, and it’s important to find an effective therapeutic option. As a general guideline, clinicians start anxiety patients on low dosages that give 2 to 20 mg of cannabinoids in one dose before bedtime before gradually increasing doses. It’s best to begin with CBD only for people who are concerned about the intoxicating effect of THC. As with any cannabis prescription, it’s critical for individuals dealing with anxiety to keep a detailed record of dosage, timing, symptom alleviation, and unwanted effects. Taking note of an increase in anxiety after dosing is especially important to determine the optimum dosage for anxiety reduction. CBD may be used at that dose during the day to treat episodic and/or chronic anxiety symptoms once effective night-time dosing has been established if you’re taking into account the “sweet spot.”
Microdosing—a growing trend in cannabis use among those looking to avoid THC’s intoxicating effects while also maintaining productivity—involves taking tiny doses of marijuana for medical purposes to limit THC’s psychoactive properties and keep daily life stable. Microdosing is ideal for people who want to deal with anxiety symptoms since it has a minimal psychological impact and allows them to administer smaller doses of anxiety throughout the day. In a 2014 experiment, low (4 mg) doses of nabilone (synthetic THC and a CB1 agonist) were given to jail inmates with post-traumatic stress disorder and anxiety. Significant alleviation in PTSD-related insomnia, nightmares, general anxiety symptoms, and chronic pain was observed.22 Because cannabinoid metabolism varies considerably among individuals, it’s difficult to offer precise microdosing guidelines. Microdosing with sublingual tinctures is the most popular method since the CBD:THC ratio and dosage are strictly controlled, and dosing is precise. For a few days, clinicians generally start patients on 2 to 2.5 mg 1:1 CBD:THC products before gradually increasing if needed. A microdose is defined as one puff at a time. While edibles can be split into microdoses, it’s not advised because achieving consistent CBD:THC throughout the product would be difficult, and first-pass liver metabolism will alter cannabinoid metabolites in the body.
7 Misconceptions About Using Cannabis for Anxiety
1. Medical cannabis doesn’t produce a “high.” While the objective is to cure symptoms without getting high, too much THC may produce a “high” and interfere with normal daily tasks.
2. CBD alone is a helpful treatment. CBD oil has been shown to help with anxiety symptoms. THC, on the other hand, is a chemical equivalent of anandamide, which has the greatest affinity for CB1 receptors and hence improves serotonin neurotransmission.
3. High doses of cannabis aren’t harmful. The biphasic nature of cannabinoids is something that cannabis researchers all agree on. Low doses have anxiolyticlike effects, whilst higher doses have anxiogeniclike effects, such as paranoia and psychotic episodes.
4. All natural is better than pharmaceuticals. Some individuals think that cannabis is superior to pharmaceuticals since it is “natural.” However, all types of therapy should be considered during a personalized anxiety treatment strategy.
5. Continuous use is necessary. The endocannabinoid system’s (ECS) major duty is equilibrium. When ECS function is impaired, cannabis may be utilized to help the body return to normalcy. Cannabis use after balance has been restored may not be required.
6. Cannabis can’t make it worse. It’s critical to keep track of how cannabis affects your body and stop using it if you detect any changes.
7. Clinicians aren’t necessary in the use of medical cannabis. Educating and advising people on how to utilize medical marijuana effectively is the job of skilled health care providers. They also examine patient experiences and offer further recommendations for optimum results.
Because more focus is being placed on cannabis in the treatment of anxiety disorders, it’s critical that clinicians understand the fundamentals in order to confidently and accurately answer patient queries. Patients will seek advice from friends, the internet, and budtenders (some of whom may not be properly trained) if they are not adequately informed. Cannabis can be an effective first-line or adjunct therapy if utilized as part of a tailored care strategy.