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THC: Nothing to Fear but Fear Itself

Cannabis and hemp have traveled with humans since the dawn of civilization. Cannabis has been documented as an effective medicine and wellness agent for at least five thousand years, possibly much longer. Some of the oldest known human artifacts are a ten-thousand-year-old piece of hemp fabric that has been found in ancient Mesopotamia. Humans have used cannabis-based products as food, clothes, medicine, rope and as spiritual aids since as early was we became humans. 

Attitudes toward the cannabis itself and toward the main psychoactive component of cannabis, THC, or tetrahydrocannabinol have changed along with various cultures that have come and gone during our human journey. As author American Michael Pollen notes, virtually every society has used intoxicants, and it is often quite arbitrary which intoxicants are allowed and which are demonized in any particular society. For example, in the United States cannabis was a legal medicine in the early 19th century, it became illegal for almost a century, and now it is legal in some form in most of the states. More broadly, citizens of the world are once again embracing the benefits of cannabis as a wave of legalization is sweeping across the world. 

Unfortunately, the medical community was not immune to negative messaging about cannabis and THC that came along with its illegality. There has been a tremendous amount of pressure to research, publish and play up negative aspects of cannabis and to ignore the positive. Almost all of the research was on harms not benefits. Most medical journals have demonstrated a bias against medical cannabis, until very recently. As such, while CBD and cannabis have generally been accepted by the population, most physicians have a much more negative understanding of medical cannabis in general, and of the molecule THC in particular, than is warranted.

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While it is likely true that just using CBD without THC is safer than using CBD with THC, it is also true that adding some THC into the mix can vastly expand one’s therapeutic options and efficacy. It is certainly safer to just use a Band-Aid than to use a Band-Aid and an antibiotic, but think of how much more healing you can do with both. CBD and THC work synergistically together on many of the main issues that we commonly try to treat with CBD: pain, anxiety and insomnia. This is particularly true as THC, and not CBD, is a direct agonist of the cannabinoid receptors and is often needed to take full advantage of all that the endocannabinoid system has to offer.

Take pain for example. It is often recommended to start out with just CBD because CBD can frequently, by itself, work to alleviate the patient’s discomfort, with a minimum of well-known side effects. Most cannabis specialists recommend that we add some THC into the mix fairly quickly if we don’t get the desired results. For example, in the 2021 international pain guidelines which come from twenty international cannabis pain experts, titled Consensus recommendations on dosing and administration of medical cannabis to treat chronic pain: results of a modified Delphi process the dosing algorithm includes the following: 

If 40 mg/day CBD-predominant dose does not reach treatment goals, clinicians may consider initiating 2.5 mg of THC per day and titrate by 2.5 mg THC every 2–7 days up to 40 mg/day while maintaining the same CBD-predominant dose. It is recommended to seek expert consultation if considering going above 40 mg/day THC. The THC titration frequency of 2–7 days is a large range to promote tailoring to the patient’s needs.

As a medical cannabis physician for twenty years, I can tell you that there is much chronic pain that won’t respond to just CBD and many patients at some point may need some THC. It is the same with sleep. Some people drift off with CBD but others need the extra sedation, pain control, or relaxation that THC provides to conquer their insomnia. In fact, most of the early studies done on medical cannabis were either done on dronabinol, which is synthetic THC, nabilone, which is a THC analogue, or nabiximols, which is THC and CBD in equal parts. It is only because of legal structures and availability, not because of medical considerations or guidelines, that doctors and patients have been using THC-free preparations of CBD.

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THC, and whole-plant cannabis with high levels of THC, do have their potential harms and contraindications, which all physicians and patients must be educated about. Some of these include:

  • intoxication, sedation and risk of impaired driving — patients need to be carefully educated
  • addiction — while this is less of a risk than that of alcohol or tobacco, but it is important to discuss with patients
  • need to avoid in cannabis in pregnancy and breastfeeding in most cases
  • avoid to avoid in adolescents and children due to concern about effects on brain development (except in medical cases such as epilepsy)
  • short-term memory loss, which is reversible upon discontinuation

We warn patients about these potential hazards, and just as we discuss the risks and benefits of any other medications we utilize, such as opioids and benzodiazepines. As long as patients are educated and monitored, we can safely use THC and whole-plant cannabis. Often cannabis-based medicines are safer than many of the medications we are replacing them with, if not safer. For example, it is difficult to imagine many circumstances where cannabis is as dangerous as opioids or benzodiazepines, which are much more addictive, sedating and dangerous. No one has ever died from a THC-related overdose. 

So, in summary, THC, like all other medications, should be used with caution, with care, with education, and it should be used judiciously. But, it also possesses great medical benefit, beyond what CBD by itself can provide. With THC, and the proper attention and respect it deserves, there is nothing to fear but fear itself. 

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