Relief Is Not Free: A Case Study of Athlete Cannabis Use

Case Example

“James,” is a highly competitive, elite track and field athlete who reported having trouble sleeping after returning from a sidelining injury. He admitted that he did not fully trust that his body would hold up, or that he could ever be the athlete he was before. The worry kept him up at night.

James started using cannabis and initially felt it helped him sleep. One or 2 blunts did the job at first. Over time, he found that he had to use 4 or 5 to get the same effect. Eventually, even that was not helping the way it had before. So, he added a nightcap that he says helped him relax and sleep. He did not stick with this combination regularly because he began feeling the effects of the alcohol the next morning, sometimes into the day, so he used it intermittently.

Somewhere along the way, he started vomiting and having stomach problems. He did go talk to his doctor about stomach problems but never mentioned the vomiting. When he missed practice, he tied it to stomach issues. The team worked him up for an ulcer, and looked at other medical causes, but did not find anything. There was some thought that the vomiting might be related to having anxiety, but no one connected any of it to the cannabis, and neither did he.

What He Could Feel, and What He Could Not

When we, the psychiatric team, asked James how he was doing, he felt that with his regimen he was getting sleep and, at least initially, waking up rested. We wanted to understand a little more about what rested meant to him. We inquired whether he felt rested through the night and could go about the day the way he ordinarily would, or whether he was just relieved that he had not spent the whole night awake—and still felt groggy or off during the day.

We also asked whether he felt mentally there, whether he was hearing the coaches and trainers, understanding what was being asked of him, and was able to execute. He said yes. As we talked more about sustainability, he was not as sure and later admitted it was more intermittent. He had noticed a slight decline in his speed, agility, and ability to endure. His execution was not as consistent, according to some of the coaching staff. He also described the differences as “just a hair off here and there,” but admittedly enough for him and others to notice. At that point, we had his impressions and account of the feedback but had not yet looked at his times or any metrics.

Relief may help an athlete function better when anxiety and poor sleep have been getting in the way. Accordingly, our evaluation asked 2 questions: (1) how he feels, and (2) how he is functioning—with the understanding that he can tell us the first but may not be able to objectively answer the second. This is a way of organizing the conversation, not a validated assessment tool. For a patient like James, we want to follow how he felt on waking and through practice, along with his performance times, whether he could maintain his speed and finish strong, and how often other symptoms (in this case, his stomach) were keeping him from participating.

We recognized that we needed to be cautious about concluding that cannabis caused James’ problems. We needed to learn what was happening before he started using it, what he was trying to address, and how much of that was still present. What changed around the time his consistency started to slip? What was happening in his world at the time? Were there problems in with his family, significant other, team role or relationships, media or social media pressure, and how that context might have intersected with his sleep and performance?

What the Research Tells Us

Athletes tell us that cannabis can take away the stress, anxiety, and worry. They do not ruminate over work pressures as much and they feel more relaxed. Some say it puts them into a quasi-Zen-like state that helps them drift to sleep. Many describe it as a miracle drug capable of knocking out pain, anxiety, stress, and sleep issues. Over time, several have told us the effects tend to wear off and that, like James, they need more of it to get the effect they had in the beginning.

The research lines up with what they describe. In one controlled study, healthy volunteers were given a lower or higher dose of oral THC before a stressful speaking and arithmetic task. The lower dose took some of the edge off how stressful the task felt; the higher dose did not and it worsened mood.¹ THC given to healthy volunteers can also bring on anxiety outright, though intensity seems tied to cannabinoid receptors in the amygdala, part of the brain's threat system.² Animal work with a synthetic cannabinoid suggests how the same kind of signaling can push in both directions: low and high doses act on different sets of neurons, but that has not been confirmed in human.³ In our experience, the lower doses did have an anxiolytic effect. At higher doses, athletes became somewhat disinhibited, the anxiety got worse, and they were not as calm.

What the research does not tell us is whether that calm leaves an athlete sharp. The lower dose in the aforementioned study did not measurably hurt performance on the arithmetic task. But this was not a study of athletes, and a math problem in a lab is a long way from coming off the curve at full speed. Across studies, the clearest short-term effects of cannabis fall on learning, memory, and working memory.⁴

Age may matter too. In one study, young teenagers who had already started using cannabis showed a stronger brain response to threatening faces than those who had not. The study was a single snapshot, so it cannot say whether cannabis caused that or whether more reactive kids were more likely to start using.⁵ For athletes in general, when they started using is worth asking about, especially if it was in their teens.

When the Trade Shifts

With regular use, athletes may start needing more cannabis to get the effect they remember. Hirvonen et al found lower availability of cannabinoid CB1 receptors in men who smoked cannabis daily, with availability increasing after about 4 weeks of monitored abstinence.⁶ Anxiety, irritability, restlessness, and poor sleep can emerge within 1 to 2 days after stopping cannabis use and will often worsen over the first week. For heavier users, the effects may last several weeks.⁷

With James, we instructed him to cease cannabis use. Then we explored the reasons behind his self-medication. What did he do when he was hurting or worried about his future, before he began turning to cannabis for relief? As withdrawal eases over the following weeks, we can look at whether his sleep and anxiety are improving too. If those difficulties were there before he began using, or continue as withdrawal settles, we need to consider what else may be contributing.

Athletes may remember the relief cannabis gave them and worry that they will not sleep without it, especially if they have tried stopping and spent several nights awake. This can strengthen their reliance on cannabis, especially as they experience withdrawal.

In our experience, athletes rarely swap one substance out for another; they add on, as in the case of James. When the cannabis stopped working the way it had before, he added a nightcap. When athletes add on, we must look for increased consumption, impaired performance, mood changes, and withdrawal symptoms. The alcohol will muddy the picture, as next-morning grogginess could stem from the cannabis, alcohol, or poor sleep itself.

Additional Symptoms

When we asked James about vomiting, he seemed surprised that we would connect it to his cannabis use. Friends had told him cannabis helped their nausea, and he thought it would help him too. In our work, we regularly receive similar stomach complaints in athletes who smoke heavily.

James worked on cutting back, with mindfulness, deep breathing, and guided relaxation as part of a harm-reduction approach. His stomach symptoms improved and for a while he stopped using. But the vomiting returned when he initiated cannabis use again.

We were concerned about cannabinoid hyperemesis syndrome, although we did not have enough history or follow-up to establish that diagnosis.^8,9 The criteria described by Rubio-Tapia et al include cannabis use for more than a year before symptoms begin, use averaging more than 4 times a week, and resolution of vomiting after at least 6 months of abstinence or a period spanning 3 of the patient's usual vomiting cycles. James was not off cannabis long enough for us to accurately assess that. The breathing exercises and mindfulness gave him ways to manage and help reduce his usage, but they were not treatments for the suspected syndrome, which requires stopping cannabis for sustained relief.⁸

Why the Fast Option Wins

Athletes have told us they reach for cannabis, alcohol, or a pill instead of breathing work because it is faster and easier. It also does not require repeated sessions with another human being or memorizing a protocol. Athletes already have a lot of mechanical, routine drills and a breathing protocol can feel like one more. Additionally, they are under significant pressure to perform and do not feel they have the time to wait for slower treatments, like therapy or antidepressants, to take effect.

Cannabis is social and recreational. They can smoke with friends. It gives their mind a chance to roam, which they might like. There may even be some pleasure in the act of smoking itself. Put together the speed, the immediate payoff, and the fact that there is not much work involved, and the choice becomes more understandable. However, we as a psychiatric team, can offer them alternatives.

In one study, 5 minutes a day of structured breathing over a month improved mood and lowered breathing rate more than the same time spent in mindfulness meditation.¹⁰ Mindfulness programs show small benefits for executive function and working memory, though not for attention, and they have not consistently outperformed other active approaches.¹¹

As to medications, in our experience, when an athlete's anxiety shows up as tremor and palpitations, a beta blocker can make a lot of sense. It works mostly on physical arousal symptoms and does not sedate the way other options do, though propranolol does reach the brain, and the evidence for it in anxiety disorders is thin.¹² But we also have to look for heart and respiratory conditions, which a beta blocker might affect. For an endurance athlete like James, it also blunts the heart rate response to exercise. Notably, beta blockers are banned in competition in some precision sports, so the rules for that athlete's sport must be checked.¹³

Benzodiazepines can be used short-term when there is a lot of anticipatory anxiety that does not fit the tremor-and-palpitations picture. They can also act as a bridge when someone with severe anxiety has started an antidepressant that has not kicked in yet. Dependence can develop within days to weeks, even at prescribed doses, and stopping abruptly can cause serious withdrawal.¹⁴ For an athlete who is also drinking, like James, the combination adds risk. Their use is case by case.

It is important to remember that an option that changes how an athlete feels tonight will often win out over one that pays off more over weeks.

What to Ask an Athlete

When an athlete tells us something is helping, the first thing we want to know is exactly what it is helping—not a surface answer, exactly what. Is it measurable? Do they have a before-and-after measure of their own? How does it make them feel? And have they ever felt that way without treatment?

We ask them bluntly whether we can talk to other people about it, and who they feel comfortable with. Often, it is a family member or a friend. It is rarely a trainer or a coach, and when it is, there is a good reason. That boundary needs particular care in a team setting. The organization may want to know what the athlete said, and the athlete must be able to trust what they shared stays confidential unless they agree otherwise.

At follow-up, we ask what they are tracking, like sleep. Wearable technology, such as an Oura ring, Apple watch, or Fitbit, which can follow sleep over time, can provide some useful data. While consumer wearables are not precise sleep measures, they can give the treatment team numbers to look at across visits. With James, his Apple watch data showed us his rough sleep estimates, his performance times, the practices he made, and how often his stomach kept him out.

Case Conclusion

James came to understand that his vomiting had to do with how much he was using cannabis. However, he never really gave it up. He was very attached and there was a strong psychological dependence, even though he hated vomiting, was drifting away from practice, and was not performing as well.

We agreed on a harm-reduction approach: using cannabis less and working on other modalities like mindfulness, breathing, and relaxation, so he would not reach for cannabis as much. It helped: He began attending more practices and worked toward reaching his pre-injury performance levels.

The biggest revelation for James was understanding that the relief he felt from cannabis came with a physiological cost, and even a subtler psychological cost. In some ways, it was running his life, and as an elite athlete, he wanted control over everything. At the same time, it brought him so much relief. We as a treatment team decided to take it slow and keep working on it through therapy, counseling, and the approaches previously described.

Dr Suite is a board-certified, sports psychiatrist who works with professional athletes and a former adjunct clinical professor of psychopharmacology at Teachers College, Columbia University.

Dr Morales is an addiction and sports psychiatrist who works with professional athletes and completed his addiction psychiatry fellowship at Mass General Brigham.

References

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13. World Anti-Doping Code International Standard: Prohibited List 2026. World Anti-Doping Agency. 2026. Accessed October 12, 2026. https://www.wada-ama.org/en/prohibited-list

14. FDA requiring Boxed Warning updated to improve safe use of benzodiazepine drug class. US Food and Drug Administration. September 23, 2020. Accessed October 12, 2026. https://www.fda.gov/drugs/drug-safety-and-availability/fda-requiring-boxed-warning-updated-improve-safe-use-benzodiazepine-drug-class