Introduction

Definition of cannabis addiction

In 2023, over 55 million Americans used marijuana, also known as cannabis. About 3 out of 10 people using cannabis have Cannabis use disorder  (CUD) with a 10% likelihood of cannabis addiction. Cannabis use disorder is a condition where cannabis is used in a disturbing pattern, thus affecting daily living activities, ranging from mild to severe. Cannabis addiction is a severe form of CUD. Cannabis addiction has three different components:¹

• Preoccupation with how to acquire cannabis
• Compulsive need to use cannabis
• Relapse use of cannabis in cases of withdrawal

Cannabis is an extract of any part of the Cannabis sativa or Cannabis indica plant containing delta-9-tetrahydrocannabinol (THC) and cannabidiol, which are potent substances affecting the nervous system of humans. Cannabis is used as a medicinal drug for extreme pain and other diseases. About 25% of patients with medically prescribed cannabis have cannabis use disorder.² 

Overview of anxiety disorders

Anxiety disorders are a common mental health challenge worldwide. About 301 million people were affected by anxiety disorders in 2019, involving more people assigned female at birth. Fear and worry are part of every human’s daily life. In anxiety disorders, the fear and worry experienced are intense and extreme, causing dysfunction in daily activities, overreactions, lack of control in behavioural patterns, and avoidance of perceived persistent danger.³   

Types of anxiety disorders

There are various types of anxiety disorders. They include the following:

• Generalised anxiety disorders: This is a condition characterised by excessive and intense fear and worry about general living activities and needs. It can sometimes be a side effect of medications or drug abuse
• Panic disorder: This is a sudden onset of fear that is temporary and intense, characterised by rapid breathing, increased heart rate, and sweating
• Agoraphobia: This is intense fear and worry when one finds oneself in a situation they can’t get out of or get help
• Obsessive-compulsive disorders: This is  a health disorder where there are unwanted thoughts that cause repetitive behavioural patterns, which cause anxiety that needs to be treated with medications
• Post-traumatic stress disorder: This is anxiety usually caused by a past traumatic event 
• Social anxiety disorder: Anxiety in this context is caused by the fear of societal judgment, norms and beliefs
• Separation anxiety disorder: This is anxiety caused by separation from a family member, friend, or loved one, and it occurs mostly in children 
• Other phobias
• Selective mutism

Symptoms of anxiety disorders

  People with anxiety disorders usually present with the following symptoms: 

• Difficult to concentrate or make decisions
• Restlessness and irritability
• Rapid breathing, rapid heart rate, and sweating
• Trembling or shaking
• Difficulty sleeping
• Constant fear and panic of future danger 

Understanding cannabis addiction

Mechanism of action

Delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD) are the most potent components in cannabis addiction. They get into the human body either through inhalation or oral ingestion. 

• When inhaled, THC and CBD enter the bloodstream through the lungs about 10 minutes after inhalation. The proportion of THC and CBD that enter the circulation following inhalation is between 10% and 35%⁴
• When ingested, it is absorbed in the intestines and transported to the liver, where it is metabolised. A great majority of the cases are eliminated through faeces and urine; however, a small percentage of the cases are eliminated through the bloodstream and reach the heart. The proportion of THC and CBD that enter the circulation following ingestion is between 4% and 12%⁴

About 65% of ingested cannabis is eliminated through faeces, and 20% through urine. About 80% to 90% of cannabis is excreted within 5 days. THC dissolves rapidly in fats, is taken up and stored in fatty bodies, and later released into the blood circulation. The psychoactive effect of cannabis is seen when THC and CBD reach the brain. This is mostly achieved through the inhalation route. The effects of CBD in blood circulation last longer than those of THC.^4,5

Patterns and prevalence of cannabis use

The use of cannabis increased between 2013 and 2019 from 7.59% to 11.48%, then between 2021 and 2022 from 13.13% to 15.11% in the USA, as discussed by Mattingly and collaborators. Cannabis use in the youth sample of the above study remained constant over the years.⁶ In addition, cardiac patients in Canada registered a percentage rate of 13.8% cannabis use between 2019 and 2020.⁷ 

Dependency and withdrawal symptoms

According to the Statistical Manual of Mental Disorders (DSM-5), the following withdrawal symptoms develop within approximately 1 week following cessation of cannabis use after chronic cannabis use. These include:⁸

• Irritability, anger or aggression 
• Nervousness or anxiety 
• Sleep difficulty (insomnia, disturbing dreams) 
• Decreased appetite or weight loss 
• Restlessness – Depressed mood 
• Sometimes: abdominal pain, tremor, perspiration, fever, chills, or headache 

The bidirectional relationship between cannabis use and anxiety

Cannabis use contributes to anxiety

Short-term effects

• THC, which is a psychoactive component of cannabis, causes relaxation and euphoria when taken in the right dosage. As such, it can be used to relieve and manage anxiety⁹
• CBD, which is also a psychoactive component in cannabis, have anxiolytic (relieves anxiety) effects, and as such, is used by cannabis addicts to relieve anxiety⁴
• Even though cannabis relieves anxiety, high doses of THC, especially in new users and persons predisposed to anxiety, can provoke acute anxiety, paranoia, and sometimes panic attacks⁹

Long-term effects

People who have used cannabis for a long time are likely to develop anxiety disorders. This is common in cannabis users with pre-existing mental conditions or who are genetically predisposed to mental health conditions.⁹ A percentage rate of 17.3% of cannabis-induced anxiety was seen in an emergency centre in Michigan in 2018.¹⁰

The recurrent use of cannabis causes the development of cannabis resistance, as with any other medication. These make chronic users or addicts seek higher doses of cannabis to achieve similar effects, and develop withdrawal symptoms like anxiety and others when inhalation or ingestion of cannabis is stopped or reduced.¹¹

Anxiety disorders leading to cannabis use

Persons suffering from anxiety disorders usually resort to cannabis use as a form of self-treatment and escape from their present medical conditions. It is seen as a natural and less harmful alternative to medications.¹² People with higher levels of anxiety may use cannabis more frequently to manage symptoms, which could lead to dependency.¹¹

Treatment approaches

There are various therapeutic approaches to the management of Cannabis use disorders and Cannabis addiction.¹³ The most widely used approach includes:

Cognitive-behavioural therapy (CBT)

This aims to develop coping strategies that are effective, improve problem-solving skills and encourage relaxation approaches. This method focuses on disturbing thoughts and behavioural patterns that serve as triggers to the use of cannabis.¹⁴

Motivational enhancement therapy (MET) 

This promotes a good relationship that is non-judgmental, empathic and supportive between the therapist and the cannabis user. Patients are assisted to resolve mixed feelings and set out goals to rectify cannabis use.¹⁴

The above therapies are usually combined for better effectiveness.^{13, 14} 

Other therapeutic measures include:¹⁴

• Contingency Management
• Mindfulness meditation
• Mutual help groups
• Family therapy 

Prevention strategies

Strategies and programs are essential to prevent cannabis addiction, especially in youths. These strategies include:¹⁵

• Education and interventions at schools: Early-onset users of cannabis tend to develop addictions due to chronic use; thus, preventive measures are necessary in educational systems
• Digital interventions and campaigns through social media
• Culture-based interventions

All the above interventions are to create awareness on cannabis addiction, educate communities on the dangers of cannabis addiction, and empower them to detect its symptoms early in family members and loved ones.¹⁵

Summary

Cannabis addiction and anxiety are serious health challenges affecting the mental health of youths and adults worldwide. The most potent psychoactive components include delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD). While some cannabis addicts use cannabis as a means to relax and relieve anxiety, chronic usage and overdose can lead to paranoia and panic disorders. The most effective management method is a combination of Cognitive-Behavioural Therapy and Motivational Enhancement Therapy. Preventive strategies mainly involve creating public awareness and education on cannabis addiction and its health consequences, through schools, social media, and cultural settings.