As states across the country continue to embrace medical and adult-use cannabis, and activists advocate for change by claiming the plant can be a substitute for other substances like opioids, media reports are sounding the alarm about the sobering reality of cannabis addiction and problematic use. While this can be a serious challenge for some users, the issue is far more nuanced than particular observers suggest.

Several recent articles have drawn a connection between high potency cannabis products and the prevalence of pot addiction. One medical marijuana doctor, Rav Ivker, even recommended that cannabis concentrates should be illegal: "The only thing they're good for is getting really high," he told Westword. Meanwhile, a piece in the Washington Post warns of the plant’s addictive potential, claiming that not enough people know it's a problem: "Many people are unaware of marijuana addiction," the article reads. "But in the public health and medical communities, it is a well-defined disorder that includes physical withdrawal symptoms, cravings and psychological dependence. Many say it is on the rise, perhaps because of the increasing potency of genetically engineered plants and the use of concentrated products, or because more users are partaking multiple times a day."

A tray of cannabis concentrates; photo via Cannabis Reports

To begin, when talking about "addiction" as it concerns cannabis, it's important to distinguish among actual addiction, dependence, and cannabis use disorder.

Addiction is defined as a compulsive behavior, despite harmful consequences that may comprise a person's work, family, or social life. A dependence, on the other hand, is a physical condition in which a person's body habituates to the drug, such that they experience physical (and mental) withdrawal symptoms should they suddenly quit. As for cannabis use disorder — a term introduced by the DSM-5 (the Bible of mental health disorders for psychiatric professionals) — a person must exhibit two to three of 11 criteria to officially qualify, including symptoms like cravings, developing a tolerance, or spending a lot of time getting, using, or recovering from a given substance.

"Based on the DSM-5, the majority of my patients would probably have marijuana use disorder, not because marijuana is a problem for them, but because they fit the requirements," says Dr. Jake Felice, a chronic pain specialist and expert on medical cannabis. For patients who need medical marijuana to treat chronic pain, or another physical or mental condition, it's common to have both a strong desire (or craving) to use cannabis, as well as a tolerance of its effects over time — both qualifiers for cannabis use disorder. "Only in severe cases does cannabis use disorder involve addiction," says Felice. "Marijuana addiction is real, but I think it's a much more minor player than alcohol or opiates."

According to Dr. Ron Alexander, psychotherapist and founder of the OpenMind Training Institute, frequent cannabis use is contingent not on dosage level, but on genetics — whether one has a proclivity toward addictive behavior. The potential for someone to develop an addiction, he says, is often influenced by other things, such as the experience of childhood trauma. "It's about the internal neurological makeup in a person's brain, in their psyche, which is the fundamental determinant of why people will increase the dosage level, but not the cannabis itself," Alexander says. "It's less about the dose and more about what is driving a person to use, whether it's being driven by pain or pleasure."

Still, there remains the question brought up by other media reports: Do more potent cannabis products encourage heavy use and addiction, or does a predisposition for addiction drive people to consume products with high levels of THC?

A dab rig used to vaporize cannabis concentrates; photo via Cannabis Reports

Felice says he has not seen any science proving that higher THC products are more likely to cause addiction. Rather, "people with endocannabinoid deficiency syndrome might be self-selecting for stronger products, as opposed to vice versa," he says. "It might be a correlation, rather than a causation."

It's easy to mix up abuse of any kind, says Jan Roberts, CEO and Director of Translational Research at the International Research Center on Cannabis and Mental Health (IRCCMH), but whether in regard to cannabis or anything else, it's less about the substance and more about poor coping skills. "You can abuse sex, food, wine, you can abuse anything," she says. Like Felice, she too says she has not seen any increase in cannabis abuse.

"It's like we're trying to apply [ideas about a drug like] heroin to a drug that is nothing like that," Roberts says. "We've let policy dictate research instead of research dictating policy, and that's why we have articles like [this]."

The issue of substance abuse is nothing new, but the stigma surrounding it seems to have stuck around, too. The social judgments surrounding disordered drug use carry the risk of sending people with problematic behaviors underground, rather than giving patients space to open up about potentially harmful relationships with substances, says Roberts.

"There is a biphasic effect with cannabis if you want to have the right amount," she says, meaning that small doses can have the opposite effect as larger doses. If you want to use THC for anxiety relief, for example, 10 milligrams might be perfect, while 20 milligrams could send you into panic. "If you want to use it for therapeutic purposes, you want to have not too little and not too much," Roberts says. "If you're having issues with motivation, that's a huge thing to look at and can be a factor if you're using too much cannabis."

In fact, research has found that people who smoke stronger forms of cannabis may tend to smoke less, since they titrate their doses themselves. According to a research study published in 2014 by the Society for the Study of Addiction, cannabis consumers were found to self-regulate their THC intake by inhaling less smoke when smoking more potent joints. Nonetheless, researchers also found that "this does not fully compensate for the higher cannabis doses per joint when using strong cannabis." Hence, those who consume more cannabis are predictably exposed to more THC. Still, their consumption habits can be viewed as a predictor of cannabis dependence more so than their monthly THC dosages.

Vape pens filled with cannabis concentrate; photo via Weed Porn Daily

"If you look at the physiological pieces of people having to use more cannabis, the reality is if you stop for a day or two, you go back to your baseline [tolerance]," says Roberts. When examining cannabis dependence, the science provides some nuanced, if not somewhat conflicting evidence.

In another 2017 study from the University of Crete’s Laboratory of Behavioral Neuroscience, researchers found that THC "does not have the capacity to induce physical dependence, since there is no evidence for robust spontaneous withdrawal."

Admittedly, the symptoms of cannabis withdrawal are rather subtle — namely irritability and anxiety — especially in contrast to the more serious physical ailments brought about by suddenly abstaining from harder drugs like opiates or even alcohol.

What's unique about cannabis is that unlike stronger narcotics, products made from the plant itself can also be used to treat symptoms of THC withdrawal. High CBD strains, for instance, can be used to quell THC withdrawal, Dr. Felice points out. However, just because someone experiences withdrawal from a substance doesn't mean it can't be used as a medication, he notes. For example, people who take Aleve or Advil everyday for headaches may experience a "rebound headache" when they stop.

Often, the symptoms of cannabis withdrawal may be an expression of the underlying psychological factors that drove the person to develop the dependence anyway. In one 2016 study published in the Journal of Studies on Alcohol and Drugs, researchers found "anxiety sensitivity and distress intolerance" to be predictors of cannabis dependence symptoms, problems, and cravings. According to the study, an estimated 43 to 48 percent of people with cannabis use disorder also have an anxiety or mood disorder.

Part of the issue is that when patients are in fact trying to self-medicate with a cannabis product, they're relying on budtenders for medical information. Lacking the proper medical training to help consumers make well-informed choices around cannabis, it can be hard for patients to make the proper medical decisions when choosing their products and deciding how much to consume, Roberts points out.

"Punishing patients by taking this medicine away from them is not the solution," says Jahan Marcu, COO and Director of Experimental Pharmacology and Behavioral Research at IRCCMH and Chief Science Officer at Americans for Safe Access. "Hyperbole takes away from the real discussion and takes away from protecting public health."

Patron inhaling vaporized cannabis concentrate; photo via Cannabis Reports

Even though the cannabis products of recent years may show an increase in potency, for the majority of humanity's relationship with cannabis, people have consumed the plant in the form of hashish or some concentrated extract, points out Marcu. "It's a bit of a red herring to talk about potency as if it's a new thing when throughout human history, people were making extracts like hash and consuming them," he says. Historically, these extracted cannabis products could have had between 50 and 70 percent THC, he adds, as evidenced by archaeological discoveries.

Moreover, says Marcu, when we talk about people who go into treatment for cannabis, it's important to remember that a percentage of patients are court-ordered, given the choice to either go to jail or get substance abuse treatment. Hence, the stats for marijuana addiction may be significantly inflated. "People need to suss out the politics and laws from the science of the physiology," says Marcu. "Just because more people go into treatment because of cannabis dependence doesn't mean they're there because of that."

The greater risk from extracts and other high potency products isn't the proclivity toward a cannabis use disorder, but the potential exposure to contaminants, he adds. When cannabinoids get concentrated, so do the chemicals they're coated with, which is why testing cannabis products is so vital.

At the core of the issue, an educated cannabis consumer is key to promoting healthy use — whether a person simply doesn't know how to treat their condition, or whether they're trying, consciously or not, to medicate an underlying psychological issue or endocannabinoid deficiency. But the way patients, doctors, and especially media cover the issue itself is sensitive, requiring careful attention to nuance and statistical interrogation, as we craft policies and harm reduction practices around cannabis and health going forward.