Basic cannabis science is useful for clinicians

After California legalized medicinal marijuana in 1996, I wrote White Papers on potential medical uses of cannabis-based medications and the impact of cannabis on youth for the California Society of Addiction Medicine and followed the basic science and clinical literature to provide updates at CSAM conferences.

As it became obvious California was going to legalize recreational use of cannabis in 2016, then Lt. Governor Gavin Newsom convened a Blue Ribbon Commission to study potential frameworks for the inevitable legalization. As chair of the commission’s youth work group, I summarized the current literature in a series of briefs. During this work, it became clear that it is impossible to understand cannabis without familiarity with the basic science of the brain’s reaction to cannabis.

Forty years of addiction medicine practice and twenty-five years studying the literature culminated in From Bud to Brain: A Psychiatrist’s View of Marijuana to present the basic science needed by clinicians to answer patients’ questions with objective and relevant information. Understanding the basic science of our brain’s endogenous cannabinoid chemistry–the natural marijuana-like chemistry that regulates the brain’s other neurotransmitters—is the critical and essential foundation needed to understand cannabis.

The endocannabinoid neural system (ECS), consisting of endogenous transmitters mimicked by THC (anandamide, 2-AG, etc.) and presynaptic receptors (CB1 and 2), provides negative feedback on other neurotransmitters, keeping them within normal parameters. THC over activates the ECS. In the hippocampus this activation affects memory, and in the amygdala it affects anxiety and enhances the sense of novelty. THC’s cumulative effect on the ECS alters the texture of experience.

Too frequent cannabis use, however, inevitably downregulates the number of active cannabinoid receptors, with a host of consequences. With too few receptors responding to endogenous cannabinoid transmitters, ECS tone is sub-physiologic. Experientially, cannabis users may feel anxious, irritable, restless, bored and have insomnia when they lower consumption. Multiple subtle impairments may also occur, including decreased learning and memory, diminished executive functions, emotional blunting, increased impulsivity, altered assessment of risk, lack of response to novelty and decreased motivation.

But how best to discuss these phenomena with people who are convinced cannabis is not addictive, or feel stigmatized by this reality? Unfortunately, facts are less motivating than stories, and the most effective stories are those from an individual’s personal life.

The framework of motivational interviewing helps clinicians embed science into the narrative of each patient’s life. Facts become meaningful when they create cognitive dissonance between an individual’s behavior and his or her goals and values. Motivational interviewing facilitates an empathic, nonjudgmental relationship between clinician and patient and reduces resistance to inconvenient facts. Clinical vignettes illustrate this counseling process.

Approaching the topic of cannabis dependence too quickly or too directly can feel like a frontal assault to those who are committed to cannabis use. From Bud to Brain describes a way to intrigue people with the science of cannabis and make sense of cannabinoid receptor downregulation, while also providing a non-stigmatizing framework for teaching both recreational and medicinal cannabis users the early signs of cannabis overuse.

The book’s goal is to help all healthcare professionals provide a wide variety of patients, from recreational and medicinal users to heavy users, worried parents and all adolescents, with empathic, objective and relevant answers to their questions about cannabis.

From Bud to Brain: A Psychiatrist’s View of Marijuana by Timmen L. Cermak is available to purchase here.

View more blogs from Timmen on Psychology Today.