By Mark Gold, MD
The physiological cravings that accompany addiction, along with memory cues and environment triggers specific to each patient can cause a recurrence of use or relapse. As such, effective treatment needs to address a person’s behavioral health and help them learn how to cope with stress and environmental triggers.
What are Environmental Triggers?
Environmental triggers are different from physiological cravings - they are external cues, rather than internal cues that trigger a person to want to return to substance use. Often referred to in recovery circles as “people, places, and things,” these environmental triggers can cause people a great deal of anxiety and stress, and those, in turn, can result in a relapse. A recent study looks at the possibility of using cannabidiol (CBD) to help reduce cravings and anxiety for the treatment of opioid use disorder in order to reduce the possibility of relapse and overdose.
The difference between CBD and THC
There are two main natural compounds found in marijuana: cannabidiol (CBD) and tetrahydrocannabinol (THC). Each act very differently in the brain.
THC is a psychoactive compound and is an agonist, or activator, of the cannabinoid 1 (CB1) receptor - this is what produces a “high”, or a sense of euphoria
CBD is a nonintoxicating compound, and binds weakly, if at all, to the CB1 receptor, causing no high, and does not cause dependence
THC is associated with many of the negative effects of marijuana, including difficulty with thinking and problem-solving, impaired memory, hallucinations, and psychosis.1 Some research suggests that CBD can aid in the treatment of chronic pain, insomnia, and anxiety, but more investigation is needed.
What did this study find?
The study by Hurd et. al. found that CBD has the potential to help patients deal with environmental cue-induced craving and anxiety by reducing heart rate and the levels of stress hormones brought on by the sights, sounds, and people that trigger them.
Researchers conducted the study with 42 people in good health between the ages of 21 and 65 who had heroin use disorder. All the participants had to be abstinent from heroin both at the start of and during the 4-week timeframe of the study. Administering controlled amounts of CBD resulted in significantly reduced cravings and anxiety, compared to placebo. These effects also lasted up to 7 days after the initial administration of CBD. In addition, CBD reduced the environmental cue-induced physiological measures of increased heart rate and salivary cortisol levels. Importantly, researchers found no significant effects on cognition and no serious side effects.
Why is this important?
Previous research from Hurd has shown that smoking commercially available marijuana left people more susceptible to opioid use disorder and more likely to start using heroin. Hurd’s research has also shown that men carry THC (the psychoactive component of marijuana) in their sperm for 6 months. What the current study suggests is that while all this is true, it does not preclude marijuana derivatives from having any safe pharmacological value. Part of the problem today with marijuana is selective breeding that is taking the THC/CBD ratio to extremes. CBD, if tested and approved like other pharmaceuticals, can have lots of therapeutic benefits while maintaining a robust safety profile.
Hurd is, however, very clear that despite the benefits of CBD, smoking marijuana or taking commercially available edibles is not a viable treatment option. Smoking is in and of itself very harmful, and a lack of dosage control makes commercially available edibles ineffective treatments for heroin use disorder. It is also known that in much of the legal and illegal marijuana and many available edibles, the levels of the therapeutic CBD are overreported, while the levels of THC are underreported - and often high enough to be harmful.2 Hurd and the other authors suggest that moving forward with a focus on CBD-only pharmacotherapies could offer safe relief not only to patients recovering from heroin use but other people suffering from anxiety-related illnesses.
The future of treatment
The opioid epidemic continues to claim more and more lives - we have lost 300,000 people in the last decade - and improving treatment options is more crucial than ever. Methadone and buprenorphine, and naltrexone, the current treatment options are opioid agonists, partial agonists, and antagonists that address the urges, or physical cravings, created by opioids. They don’t however, address the cravings and anxiety that environmental cues can cause. The currently available treatment options for opioid use disorder are also very limited, and they don’t work for everyone. CBD may fill these gaps in treatment need, and should be further researched, due to its potential to reduce cue-induced craving and anxiety - two factors that often play a large role in relapse for drug-abstinent individuals with opioid use disorder. The promising results of this study suggest there should be a focus on creating CBD-based pharmacological therapies to treat opioid use disorder.
National Institute on Drug Abuse. (2018, June). Marijuana. Retrieved from https://www.drugabuse.gov/publications/drugfacts/marijuana
Bonn-Miller, M.O., Loflin, M.J.E., Thomas, B.F., Marcu, J.P., Hyke, T., Vandrey, R. (2017). Labeling Accuracy of Cannabidiol Extracts Sold Online. JAMA
Hurd, Y.L., Spriggs, S., Alishayev, J, Winkel, G., Gurgov, K., Kudrich, C., Oprescu, A.M., Salsitz, E., (2019). Cannabidiol for the Reduction of Cue-Induced Craving and Anxiety in Drug-Abstinent Individuals With Heroin Use Disorder: A Double-Blind Randomized Placebo-Controlled Trial. The American Journal of Psychiatry
Dr. Mark S. Gold is a teacher of the year, translational researcher, author, mentor and inventor best known for his work on the brain systems underlying the effects of opiate drugs, cocaine and food. Read more by Dr. Gold here.