Vaporized D-limonene selectively
mitigates the acute anxiogenic
effects of Δ9-
tetrahydrocannabinol in healthy
adults who intermittently use
cannabis
When d-limonene was administered alone, pharmacodynamic
outcomes did not differ from placebo. Administration of 15 mg and
30 mg THC alone produced subjective, cognitive, and physiological
effects typical of acute cannabis exposure. Ratings of anxiety-like
subjective effects qualitatively decreased as d-limonene dose
increased and concurrent administration of 30 mg THC+15 mg d-
limonene significantly reduced ratings of “anxious/nervous” and
“paranoid” compared with 30 mg THC alone. Other
pharmacodynamic effects were unchanged by d-limonene. D-
limonene plasma concentrations were dose orderly, and concurrent
administration of d-limonene did not alter THC pharmacokinetics.
Cannabis is one of the most commonly used drugs in the world, and
the prevalence of use is increasing as legalization of the drug
expands for medicinal and non-medicinal purposes (Schulenberg et
al., 2021, SAMHSA, 2020). Cannabis is often considered
synonymous with delta-9-tetrahydrocannabinol (THC), the primary
psychoactive constituent of the plant that is responsible for
producing many of its hallmark effects. Specifically, THC is a partial
agonist of cannabinoid type 1 (CB1) and type 2 (CB2) receptors and
can produce both positive (e.g., feelings of euphoria, relaxed mood)
and negative (e.g., acute anxiety and paranoia, cognitive impairment)
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effects when acutely administered (Newmeyer et al., 2017, Pertwee,
2008, Sharpe et al., 2020, Spindle et al., 2018). Cannabis plants have
been selectively bred over time to contain greater concentrations of
THC, and it is now common for cannabis flower sold in dispensaries
to contain upwards of 20–30% THC (Cash et al., 2020, Freeman et
al., 2021, Vergara et al., 2017). Beyond THC, the cannabis plant
contains hundreds of additional constituents, including cannabidiol
or CBD, so-called “minor” cannabinoids (e.g., cannabigerol or CBG,
THCV, etc.), and terpenoids or “terpenes” (e.g., d-limonene, pinene,
beta-caryophyllene; Hazekamp et al., 2016; Vergara et al., 2017;
Russo and Marcu, 2017).
Historically, THC was believed to account wholly for the acute
behavioral and psychoactive effects of cannabis and other cannabis
constituents were considered largely inconsequential (Wachtel et al.,
2002). However, an alternative view, commonly referred to as the
cannabis entourage effect theory, asserts that many constituents of
the plant (e.g., minor cannabinoids and/or terpenes) meaningfully
influence the acute effects of cannabis through either unique
pharmacological mechanisms or mechanisms that modulate the
effects of THC (Russo, 2011). Though largely untested in empirical
clinical research, the cannabis entourage effect theory has greatly
influenced cannabis industry practices, including how cannabis
products are cultivated, marketed, and consumed (Cogan, 2020).
For example, cannabis is often selectively bred to contain specific
minor cannabinoid and/or terpene profiles and there is a growing
market of products purported to principally contain minor
cannabinoids or terpenes (Cogan, 2020). Moreover, marketing
materials for cannabis products, including advertisements and
product packaging, often highlight minor cannabinoid and/or terpene
profiles and may overtly state that the effects a person can expect
to feel will differ based on these profiles (Caputi, 2022, Cogan, 2020,
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Luc et al., 2020). However, most of the claims made that relate to
specific cannabis “entourage” interactions are largely theoretical and
have not been empirically tested in controlled human studies.
To date, clinical research on interactions between THC and non-THC
constituents has focused primarily on CBD, an abundant cannabinoid
found in cannabis that, alone, typically does not produce acute
intoxicating or impairing effects (Sholler et al., 2020). Research on
THC-CBD interactions has been mixed, with some studies showing
that CBD exacerbates THC’s effects (Arkell et al., 2020, Bansal et al.,
2023, Zamarripa et al., 2023), some showing that CBD mitigates
THC’s effects (Englund et al., 2013, Zuardi et al., 1982), and others
showing no modulatory effects of CBD on THC (Haney et al., 2016,
Ilan et al., 2005). The conflicting results across studies are likely due
to methodological differences, including THC/CBD doses, timing of
drug dosing, and route of administration. Beyond CBD, there are
various other cannabis constituents believed to influence the effects
of cannabis that remain understudied, including the terpene d-
limonene (Russo, 2011).
D-limonene is one of the most abundant terpenes in the cannabis
plant, though concentrations may vary widely across chemovars, and
is ubiquitous in citrus fruits (e.g., lemons; Noma and Asakawa., 2010;
Russo, 2011). Studies suggest that d-limonene has anxiolytic (i.e.,
anxiety-reducing) properties. For example, preclinical studies have
demonstrated that d-limonene or citrus essential oils high in d-
limonene reduce anxiety-like behavior in rodents, as evidenced by
behavioral paradigms such the elevated plus maze and open field
task (Buchbauer et al., 1993, Carvalho-Freitas and Costa, 2002,
Komiya et al., 2006, Song et al., 2021). These findings have been
replicated in a couple small clinical studies. For example, in one
study, hospital patients undergoing a stressful bone marrow
procedure were exposed in ambient air to a d-limonene-dominant
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essential oil or placebo (a saline solution), or an oral dose of
diazepam; d-limonene lowered self-reported anxiety on the State-
Trait Anxiety Inventory (STAI-S) and reduced blood pressure and
heart rate (HR) relative to baseline, while the placebo did not elicit
any of these effects and diazepam only reduced blood pressure
(Pimenta et al., 2016). In a second clinical study that was not
placebo-controlled, individuals hospitalized with depression were
exposed in ambient air to a citrus fragrance containing
predominantly d-limonene and reductions in depression on the
Hamilton Rating Scale for Depression (HRSD) were observed, along
with reductions in urinary cortisol and dopamine, and normalization
of biomarkers of immune function (Komori et al., 1995). Though
these prior studies collectively suggest that limonene may possess
anxiolytic properties, controlled research to understand whether d-
limonene may alter THC-induced anxiety or other pharmacodynamic
effects is lacking.
Pharmaceutical formulations of THC (dronabinol) or the THC analog
nabilone are widely approved for treating chemotherapy-induced
nausea or to stimulate appetite in certain clinical populations (e.g.,
individuals with advanced HIV/AIDS; Beal et al., 1995, Beal et al.,
1997). However, use of these medications is limited, in part, due to a
narrow therapeutic index (i.e., an effective therapeutic dose is close
to a dose that may elicit an adverse event; D'Souza et al., 2004;
Favrat et al., 2005). As noted above, one of the most common
adverse effects associated with THC or THC-dominant cannabis is
acute anxiety or paranoid/panicked reactions (Freeman et al., 2015);
these reactions are mediated via modulation of CB1 receptors in the
amygdala by THC following cannabis use (Bhattacharyya et al.,
2017). Thus, the development of novel THC-based medications that
mitigate the anxiogenic effects of THC, hence widening its
therapeutic index, could be of considerable clinical benefit. Rigorous
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controlled clinical studies are necessary to examine whether
alternative cannabis constituents aside from CBD, such as d-
limonene, may increase the tolerability of THC.
Given d-limonene’s purported anxiolytic properties, the primary aim
of the present controlled human laboratory study was to examine
whether d-limonene acutely mitigates the anxiogenic effects of THC,
as hypothesized previously (Russo, 2011) and asserted in cannabis
industry claims. In addition, this study explored whether d-limonene
modulates other common subjective, cognitive, and physiological
effects of THC. Last, this study sought to determine whether d-
limonene alone produces any acute drug effects relative to placebo.
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