Can CBD help with Addiction?
Over the last decade, the popularity of the nonintoxicating component of cannabis known as CBD, or cannabidiol, has exploded like an H-bomb, with seismic ripples of curiosity and interest reverberating around the globe, and with the fallout of enthusiasm infecting tens of millions of people.
Just ten years ago, few people would have even heard of CBD, and now one in three Americans has tried it, and one in seven Americans is taking some form of it.
CBD is an FDA-approved approved medicine for certain childhood epilepsy syndromes. People are using it (with varying degree of evidential support…) for chronic pain, anxiety, and insomnia. These are some of the conditions which can help perpetuate an addiction if inadequately treated. We currently have an addiction epidemic in the United States, and the treatment, in general, is quite shoddy. CBD has increasingly been studied as a potential therapy for addiction, usually as an adjunct, not as the sole component.
What’s the evidence?
The evidence for CBD as a treatment for addiction is piling up and the proofs include both animal studies (which are not as useful) and human studies. The misused substances that are being investigated run the gamut from tobacco and alcohol to uppers like meth and cocaine, to opioids and cannabis.
Intense cravings are a miserable component of addiction and present a dangerous obstacle to recovery. As someone who is in long-term recovery from opioid addiction (17 years!), I can tell you that cravings can present an incredibly powerful impetus to restart one’s use despite best intentions, especially in early recovery.
Cues or triggers can make the cravings much worse. For example, if I had entered a pharmacy when withdrawing from opioids and I had seen the medicine bottles behind the counter I would have been extremely triggered. Cravings can become almost unbearable and can lead you crawling into an impulsive relapse.
One study assessed whether CBD was able to impact cue-induced cravings in patients with heroin use disorder who were newly abstinent. In this study, researchers gave their test subjects either four hundred or eight hundred milligrams of CBD once daily for three consecutive days and demonstrated that, in both groups, the CBD “significantly reduced both craving and anxiety induced by the presentation of salient drug cues compared with neutral cues.” This effect lasted for seven days even though they gave the CBD for only three days. In addition, there was biochemical evidence of a response: “CBD reduced the drug cue–induced physiological measures of heart rate and salivary cortisol levels.” The CBD was well tolerated.
This certainly doesn’t put CBD up on the level of “Medications for Opioid Use Disorder (MOUD)”, such as buprenorphine or methadone, which offer replacement therapy for the opioids, but it is suggestive of a benefit. A more recent study -- more of a literature search, to see how much evidence there is that CBD can play a role in treating opioid use disorder, concluded,
Growing evidence suggests that CBD could potentially be added to the standard opioid detoxification regimen to mitigate acute or protracted opioid withdrawal-related symptoms. However, most existing findings are either based on preclinical studies and/or small clinical trials. Well- designed, prospective, randomized-controlled studies evaluating the effect of CBD on managing opioid withdrawal symptoms are warranted.
We need better data, but I believe that CBD (and I believe full cannabis as well) will have a growing role as an adjunct treatment for people suffering from opioid addiction.
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Can CBD help with nicotine addiction? In a 2018 study it was found that “a single 800-mg oral dose of cannabidiol reduced the salience and pleasantness of cigarette cues, compared with placebo, after overnight cigarette abstinence in dependent smokers.” Hmm, we’ve moved on from heroin to tobacco, but CBD had the same effect on cues and cravings. What about changes in actual number of cigarettes smoked? In a 2013 study smokers were randomized to a CBD inhaler versus a placebo inhaler and told to inhale when they felt the urge to smoke. The placebo group showed no difference in numbers of cigarettes smoked, yet “those treated with CBD significantly reduced the number of cigarettes smoked by ~40% during treatment. Results also indicated some maintenance of this effect at follow-up.” As a doctor who spends a good deal of his time trying to get people to quit cigarettes, I can only wonder why on earth this isn’t being studied more aggressively, given its likely potential to help.
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Does CBD help with cannabis addiction? To start, cannabis absolutely can be addictive, though the rates of cannabis addiction have been exaggerated by broken, Drug War influenced definitions. Unfortunately, much of the addiction field never received the memo about the therapeutic benefits of “medical marijuana”. Their definitions of “Cannabis Use Disorder” rope in many medical cannabis patients as being addicted – according to current diagnostic criteria -- due to their having “tolerance” and “withdrawal.” People have tolerance and withdrawal to other medications (e.g., benzos, opioids, even SSRIs), and these two symptoms – by themselves – aren’t used to define addiction with these other substances.
As for medical treatments for Cannabis Use Disorder (a.k.a. cannabis addiction), there aren’t any medicines that have been proven to work.
I always chuckle to myself when researchers or clinicians say, “Hey, look, nabiximols (Sativex) works for cannabis use disorder” — because nabiximols is made up of THC and CBD and thus essentially is cannabis, with an extra side of CBD included. “Hey, look, vodka works for alcohol use disorder—the patient stops withdrawing, and if they drink this, they stop craving alcohol for several hours at a time.”
I guess one might argue that this using a medication like nabiximols is a controlled substitution analogous to buprenorphine (Suboxone) or methadone for opioids, but I don’t think there’s similar data of benefit to patients, such as fewer fatal overdoses (which don’t happen with cannabis . . . so it would be difficult to prove this benefit). There is merely short-term evidence of less cannabis use, which doesn’t last.
What about CBD? Can it play the same role it that we think it might play with other drugs? Can it diminish cravings for cannabis? These cravings can be quite severe and can interfere when people are trying to quit. Can it help with cannabis addiction?
The data are scarce, but a 2020 study from Lancet Psychiatry found that both the four hundred milligram and the eight hundred milligram dosages of CBD lowered the number of days of using cannabis per week (somewhat, by a fraction) as well as the cannabis metabolites in the urine. These results were modest and need to be confirmed, but they did seem to show that CBD was potentially efficacious. I’ve had some clinical success transitioning patients off of cannabis with CBD when they need to quit but can’t quite do it on their own.
What are the obstacles and challenges?
If CBD can help people with some of the miserable conditions that sustain one’s addiction, such as undertreated chronic pain, anxiety, and insomnia, and/or if it can lessen noxious cravings, then it stands to reason that CBD will plausibly play a significant role in addiction treatment. However, things that make sense and seem obvious in medicine don’t always prove to be true – there are many examples of this over the years (e.g., doctors used to give menopausal women hormone replacement treatment until it was proven to increase heart attacks and strokes). We need much more and better data of the efficacy of CBD in treating various addictions before we pin our hopes on this (relatively non-toxic) remedy.
Other obstacles are to the use of CBD are:
1) Unclear and inconsistent legality. (It is legal in most places in the US but you have to check, especially if you are traveling overseas.)
2) Poor quality of CBD products, because this industry is wholly unregulated and unsupervised.
3) Affordability – CBD is ridiculously expensive, especially at the dosages that are likely to be effective (i.e., often in the hundreds of milligrams, not just a 30-milligram gummy).
Like all drugs and medications, CBD has side effects which need close clinical monitoring. Most of them are quite mild, including nausea and diarrhea. Occasionally, at higher doses, when taken with other medications, liver inflammation can occur. Patients who are on high dosages of CBD as well as several other drugs (such as anti-epileptics) ought to have their liver tests monitored periodically. Finally, there are drug interactions to be aware of because CBD acts in the same way that grapefruit juice does – it competes for liver enzymes. As such, CBD can raise the levels of other drugs in your blood, which can’t be cleared from your body as effectively. This is a big deal if you are taking medicines that need to be kept within a narrow therapeutic window such as blood thinners, anti-epileptics, or immunosuppressants.
What the future holds
Treating addiction is profoundly challenging for many different reasons -- beyond the often-discussed curses of stigma, criminalization, and lack of adequate resources. For some types of addiction (e.g., cannabis, stimulants) there are few if any medical treatment that have been shown to be effective. Many of the addiction treatments that are available, such as most Rehab facilities, are bogus. Consequently, as a society, we are desperate for new, more effective treatments. It is easy for our expectations to get ahead of the data. The use of CBD as a part of addiction treatment is intriguing and hopeful. But - we need far better research before routinely incorporating CBD into addiction treatment. CBD, by itself, is “not ready for showtime yet” - but stay tuned. For an addiction, always use mainstream treatments first and foremost and, potentially, add in CBD as an adjunct to the treatment regimen. We lost 107,000 people to opioids last year and 172,000 to alcohol. We don’t need to lose anyone else!