SPECIAL REPORT: CANNABIS CONUNDRUM
Lost in the various public policy arguments fueling cannabis decriminalization and legalization laws across the United States is the fact that a percentage of individuals who use cannabis will experience negative effects, ranging from bothersome to the catastrophic. These difficulties arise from a sharply decreasing perception of risk, easy availability of the drug, and increased potency of Δ-9-tetrahydrocannabinol (THC) preparations. The arithmetic of cannabis remains immutable: Best estimates are that about 9% of individuals who use cannabis will become dependent on the substance at some point in their life,1 and if the number of those who use cannabis goes up, the total number of those experiencing problems with the substance will rise also. Clinicians must learn to manage cannabis-related problems in this growing population.
The acute and chronic problems cannabis-dependent individuals face are serious, disheartening, and deserving of treatment. National Survey on Drug Use and Health (NSDUH) data on 505,796 Americans2 show that between 2008 and 2016 individuals aged 12 to 17, who met criteria for a cannabis use disorder (CUD), were 25% more common in states that had enacted Recreational marijuana laws (RMLs) as opposed to those who did not. In addition, the THC content of the various preparations of cannabis has risen over the past 10 years. Studies show that the mean THC concentration in smokable marijuana increased from 8.9% in 2008 to 17.1% in 2017,3 and half of those who frequently use marijuana ingest concentrates of at least 80% THC.4 In 2014, THC concentrate in Colorado had an average THC percentage of 56.6%, while by 2017 the average was 68.6%, with some retail stores cheerfully advertising a 95% THC rate in their products.5
Cannabis-related problems, like lack of motivation, usually become apparent after many years of use. Given cannabis’ pharmacological designation as a sedative-hypnotic substance, it is hardly surprising that common complaints on presentation to treatment include acute intoxication with high-potency edible THC preparations6; psychiatric phenomena such as depression, anxiety, and psychosis7; and cannabinoid hyperemesis syndrome (CHS).8
ALSO IN THIS SPECIAL REPORT
Clinicians should at least consider their patients’ cannabis use as a precipitating or exacerbating factor in any psychiatric or medical syndrome. Also, although the DSM-59 contains a useful list of cannabis-related signs and symptoms, many individuals with cannabis-related problems do not meet the full criteria for CUD. For instance, while the casual cannabis smoker may present with a depressive picture but meet no other criteria for CUD, cessation of cannabis use may be necessary to achieve resolution of the patient’s dysphoria, anhedonia, and fatigue. CHS, cyclic episodes of nausea and vomiting often relieved with hot baths, can be a confusing emergency department presentation. Other medical presentations of heavy cannabis smoking include cough, bronchitis, lung hyperinflation,10 as well as acute lung injury from vaping.11 Legal12 or employment13 concerns related to cannabis may also generate first visits with a clinician.
As shown in Table 1, the DSM-5 criteria list the myriad problems that can arise from cannabis use. To fulfill criteria for CUD, the patient must demonstrate at least a yearlong “problematic pattern of cannabis use” and meet at least 2 of the criteria. However, the clinician would do well to consider any cannabis-related problem as a possible contributor to the patient’s reason for presentation.
The patient should be offered a coherent psychotherapy aimed at first minimizing the harms of cannabis use, and then achieving abstinence from the substance. Treatment of any co-occurring psychiatric conditions should be initiated concurrently with the below strategies, focused on cannabis cessation. Manualized techniques like cognitive behavioral therapy,14 motivational enhancement therapy,15 and contingency management16 have shown measurable, if modest, improvements in outcome criteria such as frequency of cannabis use, number of dependence symptoms, quantity of cannabis use, and negative consequences of cannabis use. These effective treatments share a good understanding of the addictive process, practical and easily deployed interventions, and a focus on small gains. Most clinicians use a mix of therapeutic techniques, which often include cannabis-specific interventions (Table 2).
Peer-led support groups like Alcoholics Anonymous, although commonly recommended as an adjunct to the treatment of substance use disorders, should be carefully selected if recommended for the individual who uses cannabis. Members of peer support groups can be wrongly dismissive of those who only use cannabis. If possible, clinicians should recommend groups like Marijuana Anonymous,17 or specific groups which are known to understand the seriousness of CUD. Similarly, inpatient treatment or intensive outpatient programs should be carefully selected for their focus on or at least understanding of CUD.
A common—and counterproductive—fallacy about cannabis is that the substance does not cause withdrawal. In fact, the withdrawal syndrome from cannabis, though unlikely to cause serious medical problems, is uncomfortable and a leading reason that individuals who use cannabis do not stop their use of the substance. Withdrawal therefore requires treatment. Common phenomena associated with cannabis withdrawal include irritability, anxiety, depression, insomnia, disturbing dreams, anorexia, abdominal pain, tremors, sweating, fever, chills, headache,18 and craving.19
A powerful first step in engaging the patient in treatment to beat their dependence on the drug is the clinician’s acknowledgement of the withdrawal syndrome and offer to find symptomatic relief. Patients should remain well-hydrated, eat a healthy diet, and exercise regularly during the withdrawal period. Although no medications have been approved by the US Food and Drug Administration (FDA) to treat cannabis withdrawal, symptom-relief medications like gabapentin20 and the THC analogue dronabinol21 can be prescribed. Judicious use of benzodiazepines to relieve anxiety and insomnia is indicated in some cases.
Treatment of cooccurring psychiatric illnesses with the appropriate medications is vital to the treatment of CUD. Although no medications have FDA-approved indications for the specific treatment of CUD, 2 have shown suggestive data in studies, and can be prescribed for patients needing additional pharmacological support. In small studies, the anticonvulsant topiramate22 demonstrated improved retention in treatment over placebo and gabapentin19 showed better treatment retention and a decrease in cannabis use and depressive symptoms. Various trials of dronabinol and nabilone, both THC analogues; nabiximols, a combination of THC and CBD; and N-acetylcysteine, a glutamatergic modulating dietary supplement, have shown little efficacy in the treatment of CUD.23
Individuals who use cannabis may question any need for addressing their use by noting the ongoing success of cannabis legalization in the US, cannabis’ lack of lethality (as compared to opioids), and the natural provenance of the smokable varieties of cannabis. Clinicians should focus instead on the clinical issues that have brought the individual to treatment. Has the drug contributed to problems at work or school? Is there a psychiatric condition that would be better treated by psychotherapy or an actual medication? Have medical problems like hyperemesis developed? Although some individuals who use cannabis arrive in the clinic simply because a family member disapproves of cannabis use, the vast majority come in became they are being harmed in some way by their use of cannabis.
Despite the changing cultural ethos regarding cannabis, many individuals will suffer from problems related to their use of the substance. Some will meet criteria for CUD, and some will find their educational achievement, work lives, health, and relationships profoundly damaged by the drug. Along with the clinician’s attitude of encouragement and hope about recovery, effective relapse prevention therapies should be deployed. When necessary, medications for co-occurring psychiatric conditions should be used, as should the few available pharmacologic remedies for cannabis withdrawal. Clinicians engaging with patients should model a non-judgemental attitude about the substance, be realistic about the effects of cannabis, and encourage the path for reducing or stopping its use.
Dr Westreich is an associate professor of clinical psychiatry in the Division of Alcoholism and Drug Abuse, Department of Psychiatry, New York University School of Medicine in New York, New York. He also serves as the consultant on behavioral health to the commissioner of Major League Baseball.
1. Lopez-Quintero C, Pérez de los Cobos J, Hasin DS, et al. Probability and predictors of transition from first use to dependence on nicotine, alcohol, cannabis, and cocaine: results of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Drug Alcohol Depend. 2011;115(1-2):120-30.
2. Cerdá M, Mauro C, Hamilton A, et al. Association between recreational marijuana legalization in the United States and changes in marijuana use and cannabis use disorder from 2008 to 2016. JAMA Psychiatry. 2020;77(2):165-171.
3. Chandra S, Radwan MM, Majumdar CG, et al. New trends in cannabis potency in USA and Europe during the last decade (2008-2017). Eur Arch Psychiatry Clin Neurosci. 2019 Feb;269(1):5-15.
4. Bidwell LC, YorkWilliams SL, Mueller RL, et al. Exploring cannabis concentrates on the legal market: User profiles, product strength, and health-related outcomes. Addict Behav Rep. 2018 Dec; 8: 102–106.
5. Colorado Department of Public Health and Environment. Colorado monitoring health concerns related to marijuana. Accessed January 22, 2021. https://marijuanahealthinfo.colorado.gov
6. Monte A, Shelton SK, Mills E, et al. The disproportionate rate of acute clinical illness associated with cannabis edible use. Preprints Lancet. 2018.
7. Hindley G, Beck K, Borgan F, et al. Psychiatric symptoms abused by cannabis constituents: a systematic review and meta-analysis. Lancet Psychiatry. 2020;7(4):344-353.
8. Galli JA, Sawaya RA, Friedenberg FK. Cannabinoid hyperemesis syndrome. Curr Drug Abuse Rev. 2011;4(4):241-249.
9. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). American Psychiatric Publishing; 2013.
10. Yayan J, Rasche K. Damaging effects of cannabis use on the lungs. Adv Exp Med Biol. 2016;952:31-34.
11. Abeles M, Popofsky S, Wen A, et al. Vaping-associated lung injury caused by inhalation of cannabis oil. Pediatr Pulmonol. 2020; 55(1); 226-228.
12. Mead A. Legal and regulatory issues governing cannabis and cannabis-derived products in the United States. Front Plant Sci. 2019;10:697.
13. Hazle MC, Hill KP, Westreich LM. Workplace cannabis policies: a moving target. Cannabis and Cannabinoid Research. Published online November 13, 2020.
14. Stephens RS, Roffman RA, Curtin L. Comparison of extended versus brief treatments for marijuana use. J Consult Clin Psychol. 2000;68(5):898–908.
15. Stein MD, Hagerty CE, Herman DS, et al. A brief marijuana intervention for non-treatment-seeking young adult women. J Subst Abuse Treat. 2011;40(2):189–98.
16. Budney AJ, Higgins ST, Radanovich KJ, Navy PL. Adding voucher-based incentives to coping skills and motivational enhancement improves outcomes during treatment for marijuana dependence. J Consult Clin Psychol. 2000;68(6):1051–61.
17. Marijuana Anonymous World Services. Service Manual. Updated 2012. Accessed January 22, 2020. https://madistrict4.org/docs/MAServiceManualrev4_1.pdf
18. Budney AJ, Stanger C. Cannabis use and misuse. In: Rey JM, ed. IACAPAP e-Textbook of Child and Adolescent Mental Health. International Association for Child and Adolescent Psychiatry and Allied Professions; 2012.
19. Lee D, Schroeder JR, Karschner EL, et al. Cannabis withdrawal in chronic, frequent cannabis smokers during sustained abstinence within a closed residential environment. Am J Addict. 2014;23(3):234-242.
20. Mason BJ, Crean R, Goodell V, et al. A proof-of-concept randomized controlled study of gabapentin: effects on cannabis use, withdrawal and executive function deficits in cannabis dependent adults. Neuropsychopharmacology. 2012;37(7):1689-1698.
21. Levin FR, Mariani JJ, Brooks DJ, et al. Dronabinol for the treatment of cannabis dependence: A randomized, double-blind, placebo-controlled trial. Drug Alcohol Depend. 2011;116(1-3):142-150.
22. Miranda R Jr , Treloar H , Blanchard A , et al. Topiramate and motivational enhancement therapy for cannabis use among youth: a randomized placebo-controlled pilot study. Addict Biol. 2017;22(3):779-790.
23. Kondo KK, Morasco BJ, Nugent SM, et al. Pharmacotherapy for the treatment of cannabis use disorder: a systematic review. Ann of Int Med. 2020;172(6):398-412.
24. SAMHSA. Brief counseling for marijuana dependence: a manual for treating adults. 2015. http://store.samhsa.gov/product/Brief-Counseling-for-Marijuana-Dependence-A-Manual-for-Treating-Adults/sma15-4211
25. Budney AJ, Roffman R, Stephens RS, Walker D. Marijuana dependence and its treatment. Addict Sci Clin Pract. 2007;4(1):4-16. ❒