Cannabis Addiction: Real or Imagined?
By Stacey Marie Kerr MD, Hawaiian Ethos Medical Advisor
Can you really be addicted to cannabis? When we think of “addicts,” we might imagine destitute people lying in back-alley gutters, craving their fix. Cannabis may not be the first drug we associate with this image, and while cannabis addiction does not look the same as alcohol, heroin or amphetamine addiction, it does occur. That is because of a wonderful feel-good brain chemical called dopamine.
Addictive substances release dopamine to flood our brain’s reward pathways with pleasant feelings. Good food, sex, and many drugs create that delicious dopamine rush. Once we feel the effect, we want more. And more. And more. Nature created this as part of evolution, encouraging us to pursue things that would help our species survive—like sex, or a satisfying meal. But just like many functional pathways in our physiology, this one can get highjacked.
a delicate balance
The endocannabinoid system deeply interacts with dopamine pathways as part of its function to maintain balance. All the details of these intricate interactions are still being discovered, and when we introduce phytocannabinoids (plant-based cannabinoids) like THC the situation gets even more complicated. The latest scientific information shows that occasional THC use increases brain levels of dopamine, but repeated chronic use actually blunts the release of this chemical.  This is a good reason to take cannabis vacations, even if only for a day or two.
The DSM-5 definition of addiction: “… a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.”
The stimulation of dopamine release is why the intoxicating effects of THC are pleasurable to so many. But In response to large amounts of phytocannabinoids, the endocannabinoid system will decrease the production of its own naturally occurring endocannabinoids. The reward pathways become more dependent on cannabis and less functional on their own.
Interestingly, CBD does not increase the release of dopamine, so it has not been shown to be addictive.  It has, however, shown potential as a helpful intervention for addictive behaviors.  Cannabis, when used appropriately, may actually be used as tool for harm reduction rather than used as a substance of abuse.
Losing control = addiction
That’s when we feel the need to use cannabis. We may want to take a cannabis vacation, but we are unable to make ourselves stop using. It’s the loss of control that signals addiction.
Addiction, or dependence, is the result of a use disorder left untreated. Some quote the statistic that 9% of cannabis users will become addicted, a statistic that rises to 17% if the user started using in his or her teens. [4, 5, 6, 7]
If you picture addiction as we see it in relation to heroin or alcohol, it is hard to imagine cannabis causing such severe problems. But any ally we use to help us handle life’s stressors can turn into a dependence that then highjacks the dopamine reward system.
withdrawal, or symptom left untreated?
Going without cannabis after regular use may cause some physical symptoms while the brain and body adjust. Cannabis withdrawal usually isn’t physically severe, and some of the symptoms may simply be the resurgence of physical problems that cannabis was effectively addressing.
Officially, the Diagnostic Statistical Manual-5 identifies the following cannabis withdrawal as three or more of the following signs and symptoms developing within approximately 1 week after cessation of heavy, prolonged use:
Irritability, anger or aggression
Nervousness or anxiety
Sleep difficulty (like insomnia, disturbing dreams)
Decreased appetite or weight loss
At least one of the following physical symptoms causing significant discomfort: abdominal pain, shakiness/tremors, sweating, fever, chills, or headache
You may notice that some of these symptoms could have been the reason for using cannabis in the first place—anxiety, insomnia, and loss of appetite, for example. In these cases, are people simply experiencing a recurrence of the problems that were being managed with cannabis? Perhaps, but in many cases, when cannabis is withdrawn the endocannabinoid system will reset once again and be able to find and maintain homeostasis.
Take a break
Do you think you have a cannabis addiction because you may have a use disorder, have considered taking a cannabis vacation, and have been unable to do so? Addiction is when you can’t stop using even when you want to. Addiction is when you find cannabis interfering with a fully functional life, but you keep using it anyway. You do not have to be destitute, living only for your next hit of weed. To be addicted you simply need to have lost control of your own choices in life, choices that support your own health and wellbeing.
Abstinence is the treatment for cannabis addiction. Some who find themselves addicted benefit from traditional addiction interventions and groups like Marijuana Anonymous. Others are able to come to terms with their addiction and have successfully abstained on their own. Many who find themselves addicted successfully break the dependence and avoid it altogether. It helps if friends and family members are supportive and refrain from judging them for their decision to abstain. Being aware that addiction to cannabis is a real issue makes it easier to be nonjudgmental.
Pay attention to the relationship you have with your medicine. Use the least amount effective for a conscious and defined need and take occasional breaks to allow your own ECS to reset and thrive. If you can confidently say that cannabis is supporting you to live a more functional and fulfilling life, you’ll be certain that your medicine is an ally rather than a crutch robbing you of free will.
1. Bloomfield et al. The effects of Δ9-tetrahydrocannabinol on the dopamine system. Nature, 2016 November 17; 539(7629): 369–377. doi:10.1038/nature20153.
2. French, E.D., K. Dillon, and X. Wu. Cannabinoids excite dopamine neurons in the ventral tegmentum and substantia nigra. Neuroreport, 1997. 8(3): p. 649-652.
3. Prud’homme et al. Cannabidiol as an Intervention for Addictive Behaviors: A Systematic Review of the Evidence. Substance Abuse: Research and Treatment 2015:9 33–38 doi: 10.4137/SART.S25081.
4. Anthony JC, Warner LA, Kessler RC. Comparative epidemiology of dependence on tobacco, alcohol, controlled substances, and inhalants: Basic findings from the National Comorbidity Survey. Exp Clin Psychopharmacol. 1994;2(3):244-268. doi:10.1037/1064-12220.127.116.11.
5. Lopez-Quintero C, Pérez de los Cobos J, Hasin DS, et al. Probability and predictors of transition from first use to dependence on nicotine, alcohol, cannabis, and cocaine: results of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Drug Alcohol Depend. 2011;115(1-2):120-130. doi:10.1016/j.drugalcdep.2010.11.004.
6. Anthony JC. The epidemiology of cannabis dependence. In: Roffman RA, Stephens RS, eds. Cannabis Dependence: Its Nature, Consequences and Treatment. Cambridge, UK: Cambridge University Press; 2006:58-105.
7. Hall WD, Pacula RL. Cannabis Use and Dependence: Public Health and Public Policy. Cambridge, UK: Cambridge University Press; 2003.