Cannabis-Related Disorders Follow-up
- Author: Lawrence Genen, MD, MBA; Chief Editor: David Bienenfeld, MD more...
Further Outpatient Care
Follow-up care should be comprehensive and involve specialist services such as those provided by drug treatment units.
Treatment includes behavior therapy (aimed at reducing the chances of reexposure and establishing coping mechanisms to resist further use); family, group, and individual therapy; and periodic testing of urine to monitor abstinence.
Narcotics Anonymous (NA) is a self-help group organized on principles similar to Alcoholics Anonymous and is useful in helping addicts maintain abstinence.
Adolescent drug programs usually focus on promoting communication skills and age-appropriate behaviors.
Further Inpatient Care
Inpatient hospitalization for the treatment of cannabis abuse or dependence is not recommended. Additionally, inpatient treatment is not recommended for cannabis withdrawal syndrome (CWS), as CWS is only expected to occur in a subgroup of users, even among heavy, chronic users.
Inpatient & Outpatient Medications
Overall, a dearth of empirical research has focused on the role of pharmacotherapy in the treatment of cannabis dependence. A double-blinded trial examining the role of nefazodone dosed at 300 mg twice daily and bupropion-SR dosed at 150 mg twice daily demonstrated that neither medication was effective at increasing abstinence or reducing withdrawal symptoms among patients seeking treatment for cannabis dependence.
Currently, no medications have demonstrated effectiveness in the treatment of cannabis dependence or reduction of cannabis withdrawal symptoms. Time remains the best tincture for these patients.
School-based programs and peer-led groups may be useful in primary prevention of marijuana abuse.
Voucher-based reinforcement of marijuana abstinence among individuals with serious mental illness has proven effective.
Much has been made about marijuana as a “gateway drug.” Under this theory, one would expect a sequential initiation of drug use progressing from licit substances such as alcohol and tobacco to cannabis and moving on to other illicit substances. However, a recent study conducted across diverse countries and cohorts showed significant violations of this sequential gateway hypothesis and instead has demonstrated “that the strength of associations between substance use progression may be driven by background prevalence rather than being wholly explained by causal mechanisms.”
Gateway violations, such as use of illicit substances prior to cannabis use, were highest in countries with the lowest rates of prevalence of cannabis use, with similar findings of gateway violations associated with alcohol and tobacco in countries with low prevalence rates of use for alcohol and tobacco. Further, the risk for later development of drug dependence may be more affected by the extent of prior use of any drug and the age of onset at which that use began. The implications of this information for drug abuse prevention would imply that prevention efforts may be most effective not simply by targeting drugs perceived to exist earlier in the “gateway” chain, but by efforts designed to prevent all drug use.
As with all efforts to prevent drug abuse, straight-forward education on the risks associated with cannabis may be most effective. Given the increasing ease of access to marijuana, its increasing prevalence of use, and changing societal views, which seem to reflect its increasing acceptance, the scare tactics of old, which attempted to illustrate "reefer madness” may be perceived as out of touch, inaccurate, and therefore ineffective.
Marijuana use may be complicated by comorbid substance use and medical problems as outlined.
As with other substance abuse conditions, relapse is common in those meeting criteria for dependence, and treatment may be necessary for multiple episodes.
See the list below:
American Council for Drug Education, Basic Facts About Drugs: Marijuana
National Institute on Drug Abuse, Infofacts, Marijuana
National Institute on Drug Abuse, Marijuana: Facts for Teens
Office of National Drug Control Policy, Marijuana
eMedicineHealth, Substance Abuse Center
National Institute on Drug Abuse, Parents and Teachers
Cohen PJ. Medical marijuana: the conflict between scientific evidence and political ideology. Part two of two. J Pain Palliat Care Pharmacother. 2009. 23(2):120-40. [Medline].
Remnick D. Going the Distance. The New Yorker. Available at http://www.newyorker.com/reporting/2014/01/27/140127fa_fact_remnick?currentPage=all. Accessed: May 25, 2014.
O'Brien M. Poll: Majority of Americans Support Efforts to Legalize Marijuana. NBC News. Available at http://www.nbcnews.com/storyline/legal-pot/poll-majority-americans-support-efforts-legalize-marijuana-n17416. Accessed: May 25, 2014.
Frosch D. V.A. Easing Rules for Users of Medical Marijuana. The New York Times. Available at http://www.nytimes.com/2010/07/24/health/policy/24veterans.html?pagewanted=1&_r=1. Accessed: July 24, 2010.
MacCoun R, Reuter P. Evaluating alternative cannabis regimes. Br J Psychiatry. 2001 Feb. 178:123-8. [Medline].
van den Brink W. Forum: Decriminalization of cannabis. Curr Opin Psychiatry. 2008 Mar. 21(2):122-6. [Medline].
Abrams DI, Jay CA, Shade SB, et al. Cannabis in painful HIV-associated sensory neuropathy: a randomized placebo-controlled trial. Neurology. 2007 Feb 13. 68(7):515-21. [Medline].
Miller MC, et al. Medical marijuana and the mind. Harvard Mental Health Letter. April 2010. 26:1-4.
Pletcher MJ, Vittinghoff E, Kalhan R, et al. Association between marijuana exposure and pulmonary function over 20 years. JAMA. 2012 Jan 11. 307(2):173-81. [Medline].
Koppel BS, Brust JC, Fife T, Bronstein J, Youssof S, Gronseth G, et al. Systematic review: efficacy and safety of medical marijuana in selected neurologic disorders: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2014 Apr 29. 82(17):1556-63. [Medline]. [Full Text].
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, DSM-5. Washington D.C.: American Psychiatric Association; 2013.
Ringen PA, Vaskinn A, Sundet K, et al. Opposite relationships between cannabis use and neurocognitive functioning in bipolar disorder and schizophrenia. Psychol Med. 2009 Nov 6. 1-11. [Medline].
Substance Abuse and Mental Health Services Administration. Results from the 2005 National Survey on Drug Use and Health: National Findings. Rockville, MD: Office of Applied Studies, NSDUH Series H-30;. 2006. DHHS Publication No. SMA 06-4194:
National Institute on Drug Abuse: Marijuana. National Institute on Drug Abuse. Available at http://www.drugabuse.gov/drugs-abuse/marijuana.
Stinson FS, Ruan WJ, Pickering R, Grant BF. Cannabis use disorders in the USA: prevalence, correlates and co-morbidity. Psychol Med. 2006 Oct. 36(10):1447-60. [Medline].
Annual Report 2006: The State of the Drugs Problem in Europe. European Monitoring Centre for Drugs and Drug Addiction (EMCDDA).
Wilson N, Cadet JL. Comorbid mood, psychosis, and marijuana abuse disorders: a theoretical review. J Addict Dis. 2009 Oct. 28(4):309-19. [Medline].
Bosker WM, Kuypers KP, Theunissen EL, Surinx A, Blankespoor RJ, Skopp G, et al. Medicinal THC (dronabinol) impairs on-the-road driving performance of occasional and heavy cannabis users but is not detected in Standardized Field Sobriety Tests. Addiction. 2012 May 4. [Medline].
Barrigón ML, Gurpegui M, Ruiz-Veguilla M, et al. Temporal relationship of first-episode non-affective psychosis with cannabis use: a clinical verification of an epidemiological hypothesis. J Psychiatr Res. 2010 May. 44(7):413-20. [Medline].
Kuepper R, van Os J, Lieb R, Wittchen HU, Höfler M, Henquet C. Continued cannabis use and risk of incidence and persistence of psychotic symptoms: 10 year follow-up cohort study. BMJ. 2011 Mar 1. 342:d738. [Medline]. [Full Text].
Large M, Sharma S, Compton MT, Slade T, Nielssen O. Cannabis Use and Earlier Onset of Psychosis: A Systematic Meta-analysis. Arch Gen Psychiatry. 2011 Jun. 68(6):555-61. [Medline].
Peter Hecht. Report: African-Americans disproportionately targeted for pot. The Sacramento Bee. Available at http://blogs.sacbee.com/weed-wars/2010/06/report-african-americans-disproportionately-targeted-for-pot.html. Accessed: August 3, 2010.
Lopez-Quintero C, Perez 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 May 1. 115(1-2):120-30. [Medline]. [Full Text].
Preuss UW, Watzke AB, Zimmermann J, Wong JW, Schmidt CO. Cannabis withdrawal severity and short-term course among cannabis-dependent adolescent and young adult inpatients. Drug Alcohol Depend. 2010 Jan 15. 106(2-3):133-41. [Medline].
Budney AJ, Hughes JR, Moore BA, Vandrey R. Review of the validity and significance of cannabis withdrawal syndrome. Am J Psychiatry. 2004 Nov. 161(11):1967-77. [Medline].
Allsop DJ, Norberg MM, Copeland J, Fu S, Budney AJ. The Cannabis Withdrawal Scale development: Patterns and predictors of cannabis withdrawal and distress. Drug Alcohol Depend. 2011 Dec 1. 119(1-2):123-9. [Medline].
Musshoff F, Madea B. Review of biologic matrices (urine, blood, hair) as indicators of recent or ongoing cannabis use. Ther Drug Monit. 2006 Apr. 28(2):155-63. [Medline].
Carpenter KM, McDowell D, Brooks DJ, Cheng WY, Levin FR. A preliminary trial: double-blind comparison of nefazodone, bupropion-SR, and placebo in the treatment of cannabis dependence. Am J Addict. 2009 Jan-Feb. 18(1):53-64. [Medline]. [Full Text].
Degenhardt L, Dierker L, Chiu WT, et al. Evaluating the drug use "gateway" theory using cross-national data: consistency and associations of the order of initiation of drug use among participants in the WHO World Mental Health Surveys. Drug Alcohol Depend. 2010 Apr 1. 108(1-2):84-97. [Medline]. [Full Text].
Agrawal A, Lynskey MT. The genetic epidemiology of cannabis use, abuse and dependence. Addiction. 2006 Jun. 101(6):801-12. [Medline].
Degenhardt L, Hall W. Is cannabis use a contributory cause of psychosis?. Can J Psychiatry. 2006 Aug. 51(9):556-65. [Medline].
Gruber SA, Yurgelun-Todd DA. Neuroimaging of marijuana smokers during inhibitory processing: a pilot investigation. Brain Res Cogn Brain Res. 2005 Apr. 23(1):107-18. [Medline].
Haney M, Rabkin J, Gunderson E, Foltin RW. Dronabinol and marijuana in HIV(+) marijuana smokers: acute effects on caloric intake and mood. Psychopharmacology (Berl). 2005 Aug. 181(1):170-8. [Medline].
Hurd YL, Wang X, Anderson V, Beck O, Minkoff H, Dow-Edwards D. Marijuana impairs growth in mid-gestation fetuses. Neurotoxicol Teratol. 2005 Mar-Apr. 27(2):221-9. [Medline].
Iversen L. Cannabis and the brain. Brain. 2003 Jun. 126(Pt 6):1252-70. [Medline].
Johnston LD, O'Malley PM, Bachman JG, Schulenberg JE. Monitoring the Future national results on adolescent drug use: Overview of key findings, 2005. Bethesday, MD: National Institute on Drug Abuse;. 2006. NIH Publication No. 06-5882:
[Guideline] Kleber HD, Weiss RD, Anton RF, et al. Treatment of patients with substance use disorders, second edition. American Psychiatic Association. Am J Psychiatry. 2006 Aug. 163(8 Suppl):5-82. [Medline].
Ramaekers JG, Moeller MR, van Ruitenbeek P, et al. Cognition and motor control as a function of Delta9-THC concentration in serum and oral fluid: limits of impairment. Drug Alcohol Depend. 2006 Nov 8. 85(2):114-22. [Medline].
Strasser F, Luftner D, Possinger K, Ernst G, Ruhstaller T. Comparison of orally administered cannabis extract and delta-9-tetrahydrocannabinol in treating patients with cancer-related anorexia-cachexia syndrome: a multicenter, phase III, randomized, double-blind, placebo-controlled clinical trial from the Cannabis-In-Cachexia-Study-Group. J Clin Oncol. 2006 Jul 20. 24(21):3394-400. [Medline].
Whitcomb D. Marijuana legalization will be on California ballot. Reuters. Available at http://www.reuters.com/article/idUSTRE62O08U20100325. Accessed: July 24, 2010.
Zuardi AW, Crippa JA, Hallak JE, Moreira FA, Guimaraes FS. Cannabidiol, a Cannabis sativa constituent, as an antipsychotic drug. Braz J Med Biol Res. 2006 Apr. 39(4):421-9. [Medline].