The landscape of lighting up is changing. Long gone are the days of smelling marijuana and finger-wagging at the tie-dye-wearing teens lying in the grass nearby. Now, it’s just as likely to be from the elderly group of men sitting on a bench or the mom pushing a stroller. Heck, no one even smokes the stuff anymore, for that matter, thanks to the rise of oils, vaporizers, and edibles.
Among Americans who partake (roughly 22.2 million people over 12 years old), 36 percent use cannabis for both recreational and medical use, another 10 percent lighting up solely for medical benefits, according to a massive meta-analysis conducted by the National Academies of Sciences Engineering and Medicine, released in 2017. A recent study in the Annals of Internal Medicine found Americans’ view of marijuana is more favorable than prevailing opinion. That study also found that most people hold false notions about what medical conditions cannabis can actually help with. We’re here to set the record straight.
If you’ve ever wondered if cannabis can help ease your anxiety, relieve chronic pain or soothe muscle soreness, here’s a run-down of what the latest science says about it, plus how to choose a quality product that’s both safe and effective.
The Ways Cannabis Interacts with Your Body
It’s important to understand the impact plant-based cannabinoids—that’s the molecules found in cannabis—have on your body. The main way cannabinoids affect your mind and body is via your natural endocannabinoid system. “It’s a communication system between cells that helps guide development and growth of the human body with the goal of maintaining homeostasis,” says Dustin Sulak, DO, a Maine-based integrative medicine and medical cannabis physician and founder of cannabis educational resource, Healer.com.
When one kind of cellular activity becomes excessive or insufficient, the endocannabinoid system is part of that signaling cascade that corrects the over- or under-activity and restores balance. For example, when your brain is releasing too much of an excitatory neurotransmitter, neighboring nerves will produce an endocannabinoid to turn off the overactive receptor and restore homeostasis. And it’s doing that in all the tissues of the body, Sulak adds, so it’s regulating your brain, your gut, your immune system—it’s maintaining cellular homeostasis all over the body, in every tissue, in every organ.
The molecules in cannabis, particularly tetrahydrocannabinol (THC), mimic that endocannabinoid system and further affect nerve receptors. But while endocannabinoids are produced right where they’re needed and subsequently broken down after they do their job, THC enacts a global stimulation of the system, affecting your whole body at once.
The other most helpful cannabinoid, cannabidiol (CBD), acts differently—and wears a lot more hats. When it comes to the endocannabinoid system, CBD essentially slows the breakdown of an endocannabinoid, so we have more of that molecule available, for longer, Sulak explains. But CBD also works through a whole slew of different mechanisms, including stimulating and inhibiting various neurotransmitter receptors and impacting the immune system (more on that later).
Here’s a few of the ways forms of cannabis are most powerful—and most misunderstood.
1. Cannabis for Inflammation and Pain
“Chronic pain often stems from chronic inflammation, and cannabis gets to the heart of the situation, taking away not just the pain, but also the problem. You’re not just looking at a band-aid [like with other pain medications],” says Junella Chin, MD, integrative medical physician in New York and California specializing in medical cannabis and osteopathic neuromuscular medicine.
In fact, both she and Sulak agree that, from the research we have and the patients they treat, the strongest benefit of cannabis is in helping ease chronic and neuropathic pain.
Through the endocannabinoid system, CBD and THC tap into receptors (specifically the vanilloid receptor) that help control how much pain we feel. But it’s really the anti-inflammatory properties that are so powerful: The various cannabinoids in the plant extracts activate the CB2 receptors in our tissue, which controls the release of proinflammatory signals (cytokines). Additionally, THC actually gets into the cell and stimulates nuclear receptors that control the expression of genes related to inflammation and pain, Sulak explains.
The large 2017 study analysis by the National Academies of Sciences Engineering and Medicine confirms that cannabis significantly reduces pain in chronic sufferers, including less muscle spasms for adults with multiple sclerosis (MS). A 2014 study analysis by Israeli researchers reports when people with Crohn’s disease started supplementing CBD, their symptoms eased up enough that they were able to wean off their medications. In fact, one promising-but-small study found 45 percent of Crohn’s sufferers who were taking CBD actually achieved complete remission, compared to just 10 percent of those taking a placebo (though, in another study, low-dose cannabidiol had no effect).
Reducing pain has a domino effect on quality of life—for someone living with chronic pain, if you can make the pain less bothersome, your mood improves, you can sleep better, you can reduce your other meds, Sulak points out.
And it seems to be a promising alternative to opioids since cannabis actually hits the same receptors in your brain as the drugs, but delivering the same relief in a healthier way, Chin adds. But it isn’t a guaranteed relief for everyone: A recent study in The Lancet reports people suffering chronic non-cancer pain who tried to supplement their opiates with cannabis actually had more pain and less control over pain management. But, at the same time, another new study, this one in Addiction, found among states where medical cannabis became legal, use of Schedule III opioids (that’s the highly addictive vicodin, demerol, oxycodone, and fentanyl) dropped by 30 percent in the Medicare population.
Both doctors (and the prevailing body of research) agree cannabis is probably worth a few tries if you’re suffering from chronic pain.
Same goes for acute inflammation, like the kind you get from a really good workout. “A lot of athletes are now taking CBD for recovery instead of Advil or Ibuprofen, which can wreak havoc on your GI system,” Chin adds. You won’t be dosing as much as someone with, say, rheumatoid arthritis would, but if you head to a SoulCycle class and wince every time you stand up from a chair, rubbing a topical cream on your hamstrings may help you move with more ease, she says.
2. Cannabis for Anxiety
Chin, Sulak, and a whole body of research agree: CBD is very effective in treating anxiety. “People often say they feel calmer and more grounded after taking CBD,” Chin says. A 2015 study review in Neurotherapeutics found CBD is beneficial for all types of anxiety, including generalized anxiety disorder, panic disorder, social anxiety disorder, obsessive-compulsive disorder, and post-traumatic stress disorder.
Cannabis actually acts a lot like pharmaceutical treatments: “CBD works by binding with a natural brain chemical, GABA, which is a neurotransmitter that tells your body to calm down, that it’s not in danger and it doesn’t need to worry,” explains Chin. While benzodiazepines—a common anti-anxiety prescription—bind to GABA receptors synthetically, CBD does this naturally.
It’s important to note the benefit is in CBD, not THC. Researchers in Chicago found that while low-level THC (7.5 mg) did reduce stress before a public speaking event, a slightly higher dose (12.5 mg) was enough to make people actually feel more anxious. “Some people taking the 10 mg, 20 mg will have a mild anti-anxiety effect, but just know you may need a lot more CBD for severe anxiety,” Sulak warns.
Still, Chin says she’s seen CBD be effective enough to help reduce dosage of, or even replace, prescriptions like benzodiazepines, klonopin, valium, or Xanax. And unlike most anti-anxiety pharmaceuticals, CBD calms your nervous system without sedating you, Sulak adds.
3. Cannabis for Mood Disorders
There’s no research directly on depression in humans, but there are some promising findings in mice: A few studies have confirmed CBD interacts with the serotonin neuroreceptor (5-HT1A) in animals, responsible for regulating levels of the happiness hormone that keeps depression and anxiety at bay. A 2016 study in Neuropharmacology found CBD exerts an antidepressant-like effect on the brain of mice, increasing signaling in the serotonin and glutamate neuroreceptors to regulate both happiness neurochemicals and GABA production, which then helps activate the parasympathetic nervous system and keep the body calm. What’s more, researchers add CBD may actually boost serotonin levels faster than SSRIs (the most common antidepressant medication) in mice.
Marijuana’s relationship at the onset of a mental illness is a little murky: There’s evidence to suggest people who use cannabis are more likely to develop schizophrenia, other psychoses, and social anxiety disorder, as well as to a lesser extent depression. What’s more, heavy users were more likely to have suicidal thoughts and, for people with bipolar, have worse symptoms, according to a 2017 study-analysis.
Nonetheless, Chin says she has found with her non-suicidal patients who already suffer from depression that cannabis products often help with the symptoms and byproducts of both depression and depression treatment. “Because anxiety is so closely intertwined with depression and bipolar, often times getting the anxiety down works as a piece of the puzzle to ease the mood disorder,” she explains. “If you can control your anxiety with CBD, it can help you take less of the antidepressant or antipsychotic.”
Similarly, with anti-anxiety medications, antidepressants, and antipsychotics, the more you take, the more side effects come—fatigue, insomnia, brain fog, mood shifts, low libido—which just exacerbate your symptoms more. But if you can supplement with CBD and lower your pharmaceutical dosage, that can actually help reduce depression by way of reducing side effects, she explains.
4. Cannabis for Epilepsy
Even among the most cannabis-conservative states, where medical marijuana is outlawed, most allow one formula for one specific purpose: marijuana-derived CBD oil to treat epilepsy, namely in children. A 2017 study in The New England Journal of Medicine found when kids with a specific kind of drug-resistant epilepsy, Dravet syndrome, took oral CBD for 14 weeks, 43 percent saw their seizure frequency cut in half while 5 percent became seizure-free. A recent large meta-analysis published in the Journal of Neurology, Neurosurgery, and Psychiatry found patients who took cannabinoids for treatment-resistant epilepsy had an improved quality of life and over 50 percent saw a reduction or complete stop in seizures (though many also experienced more side effects like diarrhea, vomiting, fatigue, pyrexia, somnolence, and liver issues compared to a placebo). In fact, the research supporting CBD for epilepsy is so strong, the FDA actually approved an oral CBD solution for the treatment of seizures in two types of epilepsy in June 2018.
5. Cannabis for Cancer
Most of us associate medical marijuana with cancer patients—but that’s really for end-of-life care and comfort. In this context, cannabis is powerful medicine since it has the ability to knock out four major pharmaceuticals in one go, says Chin. Cannabis can help with chemotherapy-induced nausea and vomiting; chronic pain—enough so that a lot of patients will get off opioids or take less of them as they supplement cannabis, Chin adds; sleep issues and insomnia; and, as a byproduct, the constipation that often comes from the anti-nausea meds and opioids. Together, this can make life a lot more comfortable at the end.
When it comes to using cannabis while fighting cancer, some preliminary studies on cells and animal models do suggest cannabinoids may have anti-tumor properties. But we don’t have confirmation of that in humans yet, and there’s actually concern over their immunosuppressive effects potentially promoting tumor growth, as outlined by a study analysis published in Cancer Medicine earlier this year. We do know smoking marijuana doesn’t increase your risk for lung, head, and neck cancer the way tobacco does.
6. Cannabis for PTSD
“One of the most dependable, positive outcomes I can expect in my clinic is if someone who has nightmares related to PTSD starts taking cannabis, they’ll then be able to sleep through the night,” Sulak says. One case study published in The Permanente Journal in 2016 found when a young girl suffering from PTSD from sexual abuse started taking CBD oil, her anxiety was significantly reduced and she was able to get more and better quality sleep.
“Cannabis likely helps suppress dream recall and keep one relaxed, which allows people with PTSD to stay asleep,” Sulak explains. Cannabis also helps reduce what Sulak calls “re-experiencing,” which includes flashbacks, social avoidance, and hyper-vigilism, or feeling like you’re in fight or flight all the time.
The anecdotal evidence for this is so strong, in fact, that in May, the FDA approved the first-ever study of cannabis for military veterans suffering PTSD. Sulak adds this is important because the standard first line of treatment—namely antidepressants—doesn’t work for most sufferers and other anti-anxiety meds can be dangerous with long-term use.
The Risks of Cannabis Use
There aren’t a whole lot of risks to ingesting cannabis, both doctors agree. But they both also highlight that not everyone reacts the same to CBD or THC. “Cannabis has a lot of bidirectional effects—take the right amount of CBD and you feel less anxious, but take too much and it feels like you’ve drank too much caffeine. It can help relieve nausea, vomiting, diarrhea, but if you take too much, especially on the THC side, and it can cause all these things,” Sulak says.
Chin echos this notion: “I have patients who can’t use it at all, where a little bit of CBD will cause more panic attacks or cause their heart rate and blood pressure to go up.” And since THC can affect your sense of balance, there is a potential fall risk if you take too much and are unsteady on your feet.
But Chin adds most people know right away if they can’t tolerate cannabis and can rule it out immediately as an option (though you will have to sit with the discomfort for a few hours). And really, that makes it like any other medication—every body reacts different to both pharmaceuticals and plant-based medicine.
Where Buying Cannabis is Legal
The laws around legality of marijuana are downright confusing. For starters, it’s important to note that on the federal level, all forms of marijuana are illegal. “CBD and THC is considered a Schedule 1 substance under the Controlled Substances Act, meaning that it is federally illegal everywhere in the US, with the exception of products that are made specifically from the stems and seeds of imported hemp plants. Even in states with laws allowing [adult-use or medicinal marijuana], these products are still considered illegal by the federal government,” clarifies Morgan Fox, media relations director for the National Cannabis Industry Association (NCIA), an industry-led organization aimed at the growth of a responsible and legitimate cannabis industry.
That said, individual states have their own laws around what uses of marijuana are and aren’t legal, with more than 60 percent of states allowing the purchase of cannabis to some degree. At the broadest umbrella, anyone over 21 years old can purchase marijuana for any use, medicinal or recreational, in Alaska, California, Colorado, Maine, Massachusetts, Nevada, Oregon, Vermont (as of January 2018), Washington, and Washington D.C. (For the sake of accuracy, while marijuana is legal for adult use in D.C., a weird twist of law makes it so someone 21 or older can possess cannabis or be gifted it, but can’t actually purchase it in exchange for money.) Adult-use marijuana, generally, follows the same laws as alcohol—you have to be 21 and you can’t consume it in public or drive under the influence of it.
If you have a medical card from an in-state doctor, you can legally purchase certain cannabis products in Arizona, Arkansas, Connecticut, Delaware, Florida, Hawaii, Illinois, Louisiana (medicinal use approved, but available pharmacies still pending as of September 2018), Maryland, Michigan, Minnesota, Montana, New Hampshire, New Jersey, New Mexico, New York, North Dakota, Ohio, Oklahoma (signed into law July 2018, dispensaries predicted to be accessible December 2018), Pennsylvania, Rhode Island, or West Virginia.
Then, in an even more narrow category, there’s legal medicinal use of marijuana-derived CBD, typically only allowed for specific conditions like epilepsy and at specific low levels of THC. Marijuana-derived CBD is legal to some degree in all the aforementioned states as well as Alabama, Georgia, Indiana, Iowa, Kentucky, Mississippi, Missouri, North Carolina, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming.
For a visual and condensed version of the above, check out the NCIA’s state-by-state policy map:
If you live outside of these 31 states, plus D.C., you cannot legally purchase marijuana, even at the state level. There’s a loophole though: non-psychoactive, hemp-derived CBD, which is legal in all 50 states. There are a lot of technicalities, but the long and short of it is, the Controlled Substances Act only outlaws harvesting the flowering tops, resin, and leaves of a marijuana/hemp plant (where the main psychoactive compounds like THC are found), which leaves the seeds and stems—benign hemp—as legal to harvest. Hemp is classified as cannabis free of THC (which technically means less than 0.3 percent THC), though there’s no cap on the CBD quantity. While marijuana-derived CBD legality varies state to state just like THC legality (covered above), hemp-derived CBD is legal at the federal and state level nationwide. When your friend who lives in a state where marijuana hasn’t been approved for medical or recreational use talks about purchasing and using CBD oil, they’re talking about hemp-derived CBD with less than 0.3 percent THC (we’ll refer to as “legal hemp-derived CBD” from here on out), Fox confirms.
Talk to Your Doctor About It
For the general population using the plant for acute issues, like muscle soreness, mild anxiety, or mood disorders, Sulak says supplementing with cannabis is low-risk to try on your own. “In general, cannabis is extraordinarily well-tolerated, even in high doses,” he says.
If you have a serious health condition, like high blood pressure, diabetes, rheumatoid arthritis, or anything that’s life threatening, you should consult a doctor before turning to cannabis (either recreationally or medicinally). If your doctor isn’t open to the topic, find one who is.
“Most doctors don’t know how to recommend cannabis,” Sulak says, adding even ones who approve medical cards often just sign the certificate and send the patients to the dispensary for specific questions. What you want is a licensed medical cannabis physician, a specific certification provided by the state to approve someone who can be between you and your primary care physician or psychiatrist, Chin says. (Check out the directory on your state’s Department of Health or on Leafly.)
If you head straight into a dispensary for those acute issues, the budtender (that’s the person behind the counter) may be able to help guide you on what brands and dosage others like for anxiety or sleep. But there’s no standard training that everyone who works in a dispensary goes through. “It can be the equivalent of going to the health food store and asking the cashier what you should be taking for your blood pressure,” Sulak adds.
Educate yourself via sites, like Healer and Medical Cannabis Mentor, which highlight the newest research and run-downs of different strains and ratios of cannabinoids for various ailments (basically, everything you’d expect from your doctor).
If you live in a state where marijuana isn’t legal, you can find a medical cannabis certified doctor in another state who does phone consultations. But since you don’t have easy access to marijuana, you’re best bet is to try legal, hemp-based CBD.
How to Buy Quality Products
Remember how, despite individual state laws, all forms of cannabis are illegal at the federal level. Because of that, the FDA doesn’t regulate cannabis products the way it does other medications or edible items. This lack of a watchdog has created a marketplace where quality and safety of any given product is, to some degree, based solely on blind trust.
To be clear, there’s no evidence that ties contaminated marijuana to illnesses or health issues. The main question is, is this product contaminated with mold, bacteria, solvents, heavy metals, or pesticides?
Most every state does have third-party labs to confirm the formula the label is claiming—X mg of THC and Y mg of CBD—is, in fact, what the product contains and doesn’t also contain the aforementioned offenders. But not only are those tests expensive to process, but whether the cannabis products sold in dispensaries even have to be tested (and to what extent) is entirely dependent on your state.
California, for example, just changed their laws to require all products be tested for 66 pesticides, harmful chemicals, and dangerous bacteria. Oregon, meanwhile, loosened their strict requirements when the laws were creating a backlog at labs, leading to a shortage of available products. What’s more, there’s no regulation over how extractions are tested. Alaska’s two privately owned testing labs, for example, regularly report vastly different THC content results in testing the same products.
And while third-party testing is a great start to quality control, as Chin puts it, “it’s kind of like going into a supermarket and saying, yes, this can of corn really contains corn. Great to know, but it’s not necessarily reflective of the quality of the extraction.” All we really have to ensure product quality is the reputation of the brand at hand, she adds.
Legal Hemp CBD
When it comes to legal, hemp-based CBD, the water around quality and efficacy is even murkier. A sensational 2017 study published in JAMA found nearly 70 percent of CBD extracts sold online were mislabeled, with 42 percent containing higher concentrations of CBD than indicated and another 26 percent containing a lower concentration. Although there was some conflict of interest with the study’s funding, Sulak says you can safely assume that about half the products you buy outside of a dispensary don’t contain the doses they purport.
Chin adds that the majority of our hemp CBD is imported through Europe, China, and Canada and then “white labeled” by a U.S. company, so we have no confirmation or control over what kind of testing rigor that product has gone through.
That doesn’t mean you should steer clear of it all, though. “The nice thing is that something that is mislabeled is not going to be deadly, but it could be less effective or produce more side effects,” Sulak adds. Undisclosed additional THC, for example, could induce anxiety. “Every medical decision involves weighing risks and benefits.”
One other note on legal, hemp CBD: Cannabis is a complex medication that involves hundreds of plant compounds to work synergistically with one another to be maximally effective, Sulak says. “CBD, as a molecule, is good medicine. It’s absolutely safe and broadly effective. But it might not work as well as another product made from the full plant with CBD in high quantity and along with dozens of other compounds,” Sulak explains.
Because hemp-based CBD is even less regulated than medical or adult-use marijuana, product quality is all over the place. Some products work better than other—in part because of superior extraction, but also in part because a lot are “hot CBD,” or products with more than the legal 0.3 percent THC, which makes it more effective, Sulak says.
If you decide to try a hemp-based CBD product, but feel like it has no effect, try upping your dosage before switching products, Sulak advises. There’s not a lot of risk of over-dosing and some people may need 50 mg instead of the oft-recommended “serving size” of 5 mg or 10 mg.
The good news: The industry is moving quickly and pretty much everyone with a vested interest is focused on setting up quality and safety control ASAP. Until then, use these tips to ensure you’re buying quality products.
- For any purchase, educate yourself on how to maximize the benefits and minimize the side effects via sites, like Healer and Medical Cannabis Mentor.
In medical or adult-use states:
- Always shop at an official dispensary, where product is most likely to be of quality and safe, Fox says.
- Do research to see which dispensaries near you are known for their knowledgeable staff who may be able to help you understand strains and dosage, and point you toward reliable brands. Leafly offers some user-generated reviews, but Google reviews is also surprisingly helpful here.
- Research brand reputations by checking out “top product” lists from reliable sites like Leafly and High Times and asking the dispensary budtender what products they find work best for your ailment.
- Ask the budtender to see a product’s certificate of analysis—that confirms the product was tested by a state-licensed lab and that the formula is accurate, Chin says.
When purchasing hemp-based CBD in-person or online:
- Scour reviews from reliable sites like Leafly and High Times to ensure you’re buying from a reputable company.
- Opt for a tincture or lozenge rather than food, drinks, or edibles—CBD is absorbed better through blood vessel in the mouth than the gut, so you’ll get more bang for your buck with an oral delivery method, Sulak says.
- Even though certificate of analyses are less reliable for online shops (forgery is too easy), it’s still worth asking the brand or shop for testing verification, confirming the date is recent and that the batch number on the results matches the batch number you’re purchasing, Sulak says.