Medical Care

Acute intoxication of cannabis usually resolves unremarkably within 4–6 hours and is best managed by the following measures:

Frequent reassurance and maintenance of a nonthreatening environment
Minimal stimuli
Use of a specifically assigned nurse to calm the patient
Judicious use of benzodiazepines when significant anxiety is present

Consultations

People who use marijuana and are suffering from biological, psychological, or social impairment from marijuana use should be evaluated and, if necessary, treated by a psychiatrist.

The treatment of marijuana abuse follows the general principals of substance abuse, with particular attention to psychological and social aspects. Marijuana may be one of many drugs abused, and total abstinence from all psychoactive substances (with the exception of caffeine) is the treatment goal. Interventions may include psychiatric evaluation, occupational and family assessment, and implementation of a comprehensive treatment plan.

Psychological issues (eg, denial, minimization, rationalization) must be confronted. Often, cessation of drug use and subsequent cognitive improvement result in self-motivation and changes in the occupational and social well-being of the patient. Lifestyle changes, such as avoiding drug-related situations, may be encouraged.

Identify and address low self-esteem, mood disorders, family problems, and other stresses.

One-to-one therapy, group therapy, and even hospitalization may be necessary components of the treatment plan. (Patients with uncomplicated marijuana use in the absence of other psychiatric or medical problems are rarely hospitalized.)

Prevention

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 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.”^[33]

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.^[33]

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.

Long-Term Monitoring

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.

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.^[28]

Medication

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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Reinarman C, Cohen PD, Kaal HL. The limited relevance of drug policy: cannabis in Amsterdam and in San Francisco. Am J Public Health. 2004 May. 94(5):836-42. [QxMD MEDLINE Link]. [Full Text].
van den Brink W. Forum: Decriminalization of cannabis. Curr Opin Psychiatry. 2008 Mar. 21(2):122-6. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link]. [Full Text].
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. Washington D.C.: American Psychiatric Association; 2022.
Burstein SH, Zurier RB. Cannabinoids, endocannabinoids, and related analogs in inflammation. AAPS J. 2009 Mar. 11(1):109-19. [QxMD MEDLINE Link]. [Full Text].
Gertsch J, Pertwee RG, Di Marzo V. Phytocannabinoids beyond the Cannabis plant - do they exist?. Br J Pharmacol. 2010 Jun. 160(3):523-9. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
Substance Abuse and Mental Health Services Administration. Key Substance Use and Mental Health Indicators in the United States: Results from the 2020 National Survey on Drug Use and Health. Available at https://www.samhsa.gov/data/sites/default/files/reports/rpt35325/NSDUHFFRPDFWHTMLFiles2020/2020NSDUHFFR1PDFW102121.pdf. 2021; Accessed: May 3, 2022.
2021 Monitoring the Future Survey. National Institute on Drug Abuse. Available at https://nida.nih.gov/drug-topics/trends-statistics/monitoring-future. Accessed: May 3, 2022.
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. [QxMD MEDLINE Link].
Annual Report 2012: The State of the Drugs Problem in Europe. European Monitoring Centre for Drugs and Drug Addiction (EMCDDA). Available at http://www.emcdda.europa.eu/attachements.cfm/att_190854_EN_TDAC12001ENC_.pdf.
Wilson N, Cadet JL. Comorbid mood, psychosis, and marijuana abuse disorders: a theoretical review. J Addict Dis. 2009 Oct. 28(4):309-19. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Foti DJ, Kotov R, Guey LT, Bromet EJ. Cannabis use and the course of schizophrenia: 10-year follow-up after first hospitalization. Am J Psychiatry. 2010 Aug. 167(8):987-93. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link]. [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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link]. [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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link]. [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. [QxMD MEDLINE Link]. [Full Text].
Agrawal A, Lynskey MT. The genetic epidemiology of cannabis use, abuse and dependence. Addiction. 2006 Jun. 101(6):801-12. [QxMD MEDLINE Link].
Degenhardt L, Hall W. Is cannabis use a contributory cause of psychosis?. Can J Psychiatry. 2006 Aug. 51(9):556-65. [QxMD MEDLINE Link].
Di Forti M, Morgan C, Dazzan P, et al. High-potency cannabis and the risk of psychosis. Br J Psychiatry. 2009 Dec. 195(6):488-91. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Iversen L. Cannabis and the brain. Brain. 2003 Jun. 126(Pt 6):1252-70. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].

Media Gallery

Cannabis sativa.
The major psychoactive component of marijuana is tetrahydrocannabinol (THC).

of 2

Author

Lawrence Genen, MD, MBA Board Certified Psychiatrist; Diplomate, American Board of Psychiatry and Neurology; Founder, The Genen Group - A Multi-Specialty Psychiatry and Psychotherapy Practice

Disclosure: Nothing to disclose.

Coauthor(s)

John Franzen, MD Resident Physician, Department of Psychiatry, University of Nebraska-Creighton University

Disclosure: Nothing to disclose.

William F Haning, III, MD, FASAM, DFAPA Professor of Psychiatry, Director of Graduate Affairs, Office of the Dean, Program Director, Addiction Psychiatry/Medicine, Department of Psychiatry, University of Hawaii, John A Burns School of Medicine; Principal Investigator and Co-Director, Pacific Addiction Research Center

William F Haning, III, MD, FASAM, DFAPA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Addiction Psychiatry, American Medical Association, American Psychiatric Association, American Society of Addiction Medicine, Association of Military Surgeons of the US, Hawaii Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

David Bienenfeld, MD Professor, Departments of Psychiatry and Geriatric Medicine, Wright State University, Boonshoft School of Medicine

David Bienenfeld, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, Association for Academic Psychiatry

Disclosure: Nothing to disclose.

Additional Contributors

Barry I Liskow, MD Professor of Psychiatry, Vice Chairman, Psychiatry Department, Director, Psychiatric Outpatient Clinic, The University of Kansas Medical Center

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Robert C Daly, MB, ChB, MPH, BCh; Can M Savasman, MD; Caroline Fisher, MD, PhD; and Lina Cassandra Vawter, MD to the development and writing of this article.