Psychological Effects

While medicinal cannabis has been used in the treatment of mental health concerns such as anxiety and irritability, it has also had causal effect on numerous psychosocial complications. These include symptoms such as panic attacks, social anxiety, prolonged adolescence with cognitive decline, schizophrenia, paranoia, psychosis, and induced suicidality. All of these have been demonstrated with prolonged cannabis use.5,10 Some evidence of cognitive impairments have been expressed even in acute phases of consumption; including prolonged reaction times, memory and cognitive delays, which can persist for several days following last use.5

Despite the commonly held belief that cannabis does not cause a physiologic dependence in patients who use regularly, research has suggested compelling evidence to the contrary.5,10 Classic withdrawl symptoms, coined marijuana abstinence syndrome, have been reported and may include depression with and without anxiety, irritability, anorexia with weight loss, parasomnia, tremors, and even myalgia.5,10 The extent of symptoms and intolerance are challenging to predict and are often correlated with the patient’s quantity and frequency of use.10 Yet, this is generally more widely tolerated by prior users and is often only reported in approximately 50% of regular, frequent users, making the generalizability of certain risk negligible.10

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Abuse and Overdose Potential

A systematic review of the literature revealed rising opioid dependence concerns among patients with chronic pain as early as 1992, with nearly 20% of patients with evidence of substance abuse disorder.11 A similar study revealed the prevalence of opioid use disorder to be as high as nearly 33% in at-risk populations.11 A 10-year prospective study of the US population revealed the substance abuse rate had more than doubled with an estimated 43% to 45% of chronic pain patients demonstrating behavior and physiologic evidence consistent with dependence.11

In 2015, out of the 20.5 million Americans above the age of 12 who had a substance abuse problem, 2 million abused prescription pain medications and 591,000 abused heroin.22 In the same year, the leading cause of accidental death in the United States was drug overdose.22 Of the 52,404 drug overdose deaths, 33,091 were from opioid use (20,101, opioid pain medication; 12,990, heroin).22            

Contrasting these assertions of rising threats of opioid abuse were similar studies that revealed the absence of similar disease findings exhibited in patients being treated with cannabis who did not demonstrate similar signs of abuse or dependency, including irritability, parasomnia, and anxiety.16

Between 1997 and 2007, there have been no overdose related deaths attributed exclusively to cannabis use. 23 Though cause and effect cannot be safely assumed, it is interesting to note that in the states that have adopted legislation to legalize medical cannabis use starting in or prior to 2010 (Alaska, California, Colorado, Hawaii, Maine, Michigan, Montana, Nevada, New Mexico, Oregon, Rhode Island, Vermont, and Washington), there was a significantly lower (24.8%) mortality rate due to opioid overdose, as compared to states that have more restrictive laws.24

Since the institution of state medical cannabis laws, researchers have studied the effect that these laws have had on morbidity, hospital admissions, and length of stay related to treatment with cannabis vs. opioids.24 Between 1997 and 2014, medical cannabis has been associated with a 23% reduction in hospitalizations due to opioid dependence or abuse and a 13% reduction in opioid overdose.24


The United States is in the middle of a rising pandemic of opioid abuse and dependency. Medical use of cannabis may be emerging as a potential adjunct or alternative to reduce the morbidity and mortality related to opioid use. Now available in most states as a prescription alternative, with modest evidence, cannabis has been found to provide analgesia in chronic pain. Though more studies are needed to confirm the effectiveness of medical cannabis and provide reliable outcome measures, safety profile of extended use, and patient candidacy, the existing evidence is promising enough to begin a dialogue of a potential future paradigm shift in contemporary pain management.

Christopher M. Howell, DSc, MSc, MPAS, PA-C, MBA, is a program director and associate clinical professor at Miami University, in Oxford, Ohio. He works in family, emergency, and addiction medicine in Ohio and Indiana.

David Malesko, PA-C, currently practices in psychiatric medicine in Dayton, Ohio. At the time that the article was initially written, he was a student in Kettering College’s PA program in Dayton, Ohio.

Authors Disclosure: The authors neither favor nor disapprove of cannabis and similar alternative treatment strategies for both acute and chronic pain for all patients plagued with disease; as any treatment requires considering the “whole patient”. We aim only to review the evidence and risks associated with medical cannabis, as it is known to the community at this time. It is up to the practitioner to consider his or her role in current and future dialogues with colleagues industry as well as eligible patients, in determining the appropriateness of medical cannabis use.


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