The Role of Facts and Trust in Cannabis Education

By Timmen L. Cermak, MD

US Surgeon General Vivek Murthy frequently speaks of the dual roles in COVID-19 education of providing accurate, fact-based information and earning the public’s trust.  The same two elements - facts and trust - are critical for effective cannabis education.

Familiarity with three categories of facts about cannabis is necessary to provide relevant, objective answers to the wide variety of questions people ask clinicians. There are facts contained only in the basic science literature, facts contained in the clinical literature, and facts about proven medical uses of cannabis and cannabis products.

Basic science research describes the brain’s ubiquitous endogenous cannabinoid chemistry. Our endocannabinoid system (ECS) consists of typical G-protein neuroreceptors (CB1 and CB2)[1]^,[2], ligands (e.g., anandamide, 2-AG)[3], and the enzymatic machinery for their synthesis and metabolism. Nomenclature for the ECS is borrowed from the cannabis plant because THC activates its receptors, similar to how opiate receptors received their name from being activated by opium. The entire ECS is perfectly located to homeostatically regulate most other neurotransmitter systems by virtue of CB1 receptors being positioned presynaptically.[4] Synthesized on demand from arachidonic acid in postsynaptic membranes[5], the amount of endocannabinoid is determined by the amount of neurotransmitter arriving from presynaptic neurons.[6] Endocannabinoids then migrate back across the synapse to activate presynaptic cannabinoid receptors. Once these receptors are activated, negative feedback is produced to lessen the amount of neurotransmitter released with each presynaptic neuronal firing. A healthy, well-balanced ECS thus keeps other neurotransmitter systems regulated within their normal parameters. THC activates cannabinoid receptors stronger and longer than natural endocannabinoids[7], leading to downregulation of cannabinoid receptors and thereby dysregulating brain chemistry.[8] CBD, on the other hand, does not activate cannabinoid receptors but does alter their conformation to modify the effect of endocannabinoids and THC.[9]

Basic science thus describes the infrastructure needed to understand facts described in the clinical literature and that underlie the medical use of cannabis. For example, chronic cannabinoid receptor downregulation produces signs and symptoms opposite from the experience of THC’s unnaturally strong activation of the ECS (i.e., being “high”).  Instead of physical relaxation, lowered anxiety, heightened sense of novelty, increased appetite, and ease of sleep, once THC is discontinued after substantial downregulation has developed, an individual is likely to feel restlessness, anxiety/irritability, boredom, lack of appetite, and insomnia.[10]^,[11] The impact of chronic THC use is reflected in altered mental functions arising from areas of the brain where cannabinoid receptors are most densely concentrated. Hippocampal dysregulation produces measurable memory decrement.[12] Dysregulation in the frontal lobes produces a wide range of executive function decrements measured by Wisconsin Card Sort, Stroop, Iowa Gambling Task and Go/No-Go protocols.[13]^,[14],[15] Dysregulation in the amygdala produces decreased sensitivity to subtle emotional cues measured by the Masked Faces protocol.[16] And impact in the reward center increases the salience of cannabis and alters motivation, both characteristically seen in Cannabis Use Disorder.[17]

A third set of facts are summarized in the Academies of Sciences, Engineering and Medicine’s 2017 review of evidence for the medical use of cannabis and cannabis products.[18]

Their report found strong evidence for its use in treating chronic pain in adults, N/V associated with chemotherapy, and muscle spasms caused by multiple sclerosis.  In addition, CBD (Epidiolex) is approved by the FDA to treat two forms of childhood epilepsy (Gastaut and Dravet Syndrome). Preliminary evidence also exists for multiple other disease conditions that can benefit from modulation of ECS activity.[19]

These scientific facts were gathered with intense effort to eliminate bias and mere opinion. Objectivity is the highly valued Holy Grail of science. On the other hand, cannabis users have a diametrically opposite perspective. The multifaceted Cannabis Culture (i.e., consumers, legalization advocates, industry entrepreneurs, etc.) places highest value on the direct subjective experience produced by cannabis and the meanings they attribute to this experience. Of particular interest are the millennia of spiritual associations that stem from cannabis’s capacity to produce mental states that transcend the normal texture of daily experience. Why is this?

Transcendence results from a combination of THC’s interactions with oxytocin (connectedness)[20], the amygdala (awe and novelty)[21], cerebellum (timelessness)[22], cingulate gyrus (a sense of certainty)[23], and the frontal lobes (expanded range of focus and lowered filtering of otherwise distracting mental images)[24], among other influences. Famed astronomer Carl Sagan wrote of his cannabis experience, “I do not consider myself a religious person in the usual sense, but there is a religious aspect to some highs. The heightened sensitivity in all areas gives me a feeling of communion with my surroundings.”[25]

There is power in the word “communion”, defined as the state of sharing or exchanging thoughts and feelings, as well as the experience of being an integral part of something. This is precisely the point for Cannabis Culture – a community bound by sharing a deeply personal, private, subjective experience. Subjective, emotional life is the repository of our sense of humanity, wonder, and beauty far more than the rationality that motivates science. This communal sharing of subjectively perceived reality lies at the heart of spiritual communities. When cannabis education relies solely on objective facts, it is viewed suspiciously by Cannabis Culture as wildly ignorant and missing the main point about cannabis. Failure to address the mystique of cannabis can be taken as an affront to their fundamental values and a threat to their freedom.

A bridge between the objective and subjective realms must be built if cannabis education is to be successful. We build this bridge more by listening with utterly nonjudgmental curiosity to what people value about their experience with cannabis. Only after someone viewing cannabis through the lens of Cannabis Culture feels their experience has been heard and respected can they listen, without feeling assaulted, to information about how cannabis produces its “magic”, and what the unintended side effects might be.

The bottom line is that detailed facts about the science of cannabis are necessary for patient education, but far from sufficient, and often distressingly impotent by themselves. Without first earning a trusting relationship, science-based education is doomed. And a trusting relationship can only be earned on the patient’s terms, not the professional’s authority alone. While this often requires professionals to stretch outside their comfort zone, it asks no more of us than what we ask of Cannabis Culture devotees if they are to listen to the science. Such empathic listening embodies the art of addiction medicine.

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Dr. Timmen L. Cermak has recently retired from his practice of psychiatry and addiction medicine. He is a Past President of the California Society of Addiction Medicine and serves on California’s Cannabis Advisory Committee. His editorial contains excerpts from From Bud to Brain (Cambridge University Press, 2020), which summarizes the science of cannabis for health professions, and his upcoming book for the general public, Marijuana on My Mind: The Science and Mystique of Cannabis (Cambridge University Press, release date 4-20-22). Dr. Cermak welcomes comments at tcermak@aol.com