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Marijuana (Cannabis) Use Disorder

BASICS

DESCRIPTION

- Clinical presentation of acute intoxication: - Euphoria, elation, laughter, heightened sensory perception, altered perception of time, increased appetite - Poor short-term memory, concentration - Fatigue, depression - Occasionally, distrust, fear, anxiety, panic - With large doses, acute psychosis: delusions, hallucinations, loss of sense of personal identity (4)

- No intervention to date has proved consistently effective for marijuana abuse. - Despite this, trials on cognitive-behavioral therapy and contingency management have shown better outcomes in reducing marijuana use and maintaining abstinence (5). - Trials also show that addition of a comprehensive parenting training curriculum did not further enhance efficacy (5). - With marijuana abuse, most prevalent among patients suffering from other psychiatric disorders, studies indicate that treating the mental health disorder may help reduce marijuana use, particularly among heavy users and those with more chronic mental disorders. - Advice to give to patients for management of withdrawal: - Gradually reduce amount of marijuana used before cessation. - Delay first use of marijuana until later in the day. - Consider use of nicotine replacement therapy if planning to stop, separate tobacco use at the same time. - Relaxation, distraction - Avoid cues and triggers associated with cannabis use.

- Acute adverse effects - Anxiety and panic, especially in na пїЅ пїЅve users, depression - Psychotic symptoms at high doses - Motor vehicle accidents if a person drives while intoxicated - Chronic adverse effects: abnormal brain development; diminished lifetime achievement - Chronic bronchitis and impaired respiratory function in regular smokers - Psychotic symptoms and disorders in heavy users, especially those with a history of psychotic symptoms or a family history of these disorders (schizophrenia) - Addiction to marijuana and other substances

Marijuana or cannabis use disorder is classified in DSM-5 in different categories (mild, moderate, or severe) depending on how many symptoms are present. Mild: 2 to 3; Moderate: 4 to 5; Severe: 6+ (1). The definition is used leading to clinically significant impairment or distress, manifested by two or more of the following symptoms within a 12-month period: пїЅ пїЅ

  • Taken in larger amounts and over a longer period of time than intended
  • Persistent desire or unsuccessful efforts to cut down or control amount used
  • A great deal of time spent in activities is necessary to obtain, use, or recover.
  • Presence of craving for the substance
  • Recurrent use resulting in failure to fulfill major role obligations at work, school, or home
  • Continued use despite having persistent or recurrent social or interpersonal problems due to cannabis use
  • Important social, occupational, or recreational activities are given up or reduced.
  • Recurrent use in physically hazardous situations
  • Use is continued despite knowledge of having a persistent physical or psychological problem caused or exacerbated by cannabis.
  • Tolerance, defined by using increased amounts of cannabis to achieve the desired effect or intoxication or diminished effect with continued use of the same amount of cannabis
  • Withdrawal

EPIDEMIOLOGY

  • The United States is ranked first among 17 European and North American countries by the World Health Organization for prevalence of marijuana use.
  • Cannabis is the most widely used illicit psychoactive substance in the United States (2).
  • ~42% of teens will have tried marijuana by the time they graduate from high school.
  • Approximately 30% of students report having used marijuana at college entry (3).
  • In the United States, 10% of those who ever used marijuana become daily users, and 20 " пїЅ30% became weekly users.
  • In the United States, some states have approved medical marijuana use, and two states (Washington and Colorado) have approved recreational use of marijuana.
  • Other states in the United States are currently trying to pass legislation to legalize the use of recreational marijuana.

ETIOLOGY AND PATHOPHYSIOLOGY

  • Main active ingredient in marijuana: delta-9-tetrahydrocannabinol (THC)
  • When marijuana is smoked, THC rapidly passes from the lungs into the blood and to the brain, where it binds to cannabinoid receptors (CBRs).
  • CBRs are responsible for memory, thinking, concentration, sensory and time perception, pleasure, movement, and coordination.
  • THC artificially stimulates the CBRs, disrupting the function of endogenous cannabinoids. A marijuana "high " пїЅ results from overstimulation of these receptors.
  • Over time, overstimulation alters the function of CBRs, which can lead to addiction and to withdrawal symptoms when drug use stops.
  • Effects of smoked marijuana occur within minutes and can last 1 to 3 hours.
  • Effects from marijuana consumed in foods or beverages appear later, usually in 30 minutes to 1 hour but can last up to 4 hours.
  • Smoking marijuana delivers significantly more THC into the bloodstream than eating or drinking the drug.

RISK FACTORS

  • Age (highest use among those 18 to 25 years)
  • Male sex
  • Comorbid psychiatric disorders (i.e., bipolar disorder, posttraumatic stress disorder [PTSD])
  • Other substance use (i.e., alcohol, cocaine)
  • Lower educational achievement (rates of dependence is lowest among college graduates)

DIAGNOSIS

  • Screen for marijuana use along with other lifestyle questions such as tobacco and alcohol use.
  • Ask for frequency and amount used (e.g., "How long does a nickel bag last you? " пїЅ).
  • Unexplained deterioration in school or work performance may be a red flag for abuse.
  • Problems with, or changes in, social relationships (e.g., spending more time alone or with persons suspected of using drugs) and recreational activities (e.g., giving up activities that were once pleasurable) may indicate abuse.
  • If available, information from concerned parents or spouses should be obtained.

HISTORY

  • Clinical presentation of acute intoxication:Euphoria, elation, laughter, heightened sensory perception, altered perception of time, increased appetitePoor short-term memory, concentrationFatigue, depressionOccasionally, distrust, fear, anxiety, panicWith large doses, acute psychosis: delusions, hallucinations, loss of sense of personal identity (4)
  • Withdrawal symptoms include the following:NauseaWeight lossDecreased appetiteInsomniaDepressed mood

PHYSICAL EXAM

  • Evaluate for:Conjunctival injectionXerostomiaNystagmusIncreased heart rateAltered pulmonary statusAltered body temperatureReduced muscle strengthDecreased coordination
  • Withdrawal findings include the following:Restlessness/agitationIrritabilityTremorDiaphoresisIncreased body temperature

DIAGNOSTIC TESTS & INTERPRETATION

Positive urine drug screen; cannabinoids can be detected in urine weeks to months after marijuana use. пїЅ пїЅ

TREATMENT

  • Several methods of behavioral-based interventions:Cognitive-behavioral therapyMotivational interviewingCounselingContingency managementSocial network behavior therapyTwelve-step approachFamily-oriented therapyBrief interventionRelapse preventionCommunity reinforcement approach
  • No intervention to date has proved consistently effective for marijuana abuse.
  • Despite this, trials on cognitive-behavioral therapy and contingency management have shown better outcomes in reducing marijuana use and maintaining abstinence (5).
  • Trials also show that addition of a comprehensive parenting training curriculum did not further enhance efficacy (5).
  • With marijuana abuse, most prevalent among patients suffering from other psychiatric disorders, studies indicate that treating the mental health disorder may help reduce marijuana use, particularly among heavy users and those with more chronic mental disorders.
  • Advice to give to patients for management of withdrawal:Gradually reduce amount of marijuana used before cessation.Delay first use of marijuana until later in the day.Consider use of nicotine replacement therapy if planning to stop, separate tobacco use at the same time.Relaxation, distractionAvoid cues and triggers associated with cannabis use.
  • Prescribe short-term analgesia and sedation for withdrawal symptoms, if required.
  • If irritability and restlessness are marked, consider prescribing very-low-dose diazepam for 3 to 4 days.
  • Provide user and family members with information regarding marijuana abuse and withdrawal to increase understanding of the abuse and reduce likelihood of relapse.
  • Withdrawal symptoms peak on day 2 or 3, and most are over by day 7. Sleep and vivid dreams can continue for 2 to 3 weeks.

MEDICATION

  • No effective medication for the treatment of marijuana abuse
  • One study suggested oral THC could be used to abate marijuana withdrawal in individuals who are trying to quit.
  • Another study concluded medications used to treat other drug use disorders, such as buspirone, lithium, and fluoxetine, may have therapeutic benefit.

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

  • Monitor cessation of marijuana use with urine tests over several weeks for the inactive metabolite of cannabis (carboxy-THC).
  • Heavy smokers may continue to be positive for marijuana for up to 6 weeks.

PATIENT EDUCATION

To learn more about marijuana abuse, visit the National Institute on Drug Abuse (NIDA) Web site at www.drugabuse.gov. Other NIDA Web sites include the following: пїЅ пїЅ

  • https://drugpubs.drugabuse.gov/promotions/back-to-school
  • http://www.drugabuse.gov/drugs-abuse/marijuana
  • https://teens.drugabuse.gov/

COMPLICATIONS

  • Acute adverse effectsAnxiety and panic, especially in na пїЅ пїЅve users, depressionPsychotic symptoms at high dosesMotor vehicle accidents if a person drives while intoxicatedChronic adverse effects: abnormal brain development; diminished lifetime achievementChronic bronchitis and impaired respiratory function in regular smokersPsychotic symptoms and disorders in heavy users, especially those with a history of psychotic symptoms or a family history of these disorders (schizophrenia)Addiction to marijuana and other substances

REFERENCES

11 American Psychiatric Association. Substance-related and addictive disorders. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013. http://dx.doi.org/10.1176/appi.books.9780890425596.dsm16. Accessed December 2015.22 Suerken пїЅ пїЅCK, Reboussin пїЅ пїЅBA, Sutfin пїЅ пїЅEL, et al. Prevalence of marijuana use at college entry and risk factors for initiation during freshman year. Addict Behav. 2014;39(1):302 " пїЅ307.33 Hall пїЅ пїЅW, Degenhardt пїЅ пїЅL. Adverse health effects of non-medical cannabis use. Lancet. 2009;374(9698):1383 " пїЅ1391.44 Abayomi пїЅ пїЅO, Adelufosi пїЅ пїЅAO. Psychosocial interventions for cannabis abuse and/or dependence among persons with co-occurring cannabis use and psychotic disorders. Cochrane Database Syst Rev. 2015;(1):CD011488.55 Stanger пїЅ пїЅC, Ryan пїЅ пїЅSR, Scherer пїЅ пїЅEA, et al. Clinic- and home-based contingency management plus parent training for adolescent cannabis use disorders. J Am Acad Child Adolesc Psychiatry. 2015;54(6):445 " пїЅ453.e2.

ADDITIONAL READING

  • Budney пїЅ пїЅAJ, Vandrey пїЅ пїЅRG, Hughes пїЅ пїЅJR, et al. Oral delta-9-tetrahydrocannabinol suppresses cannabis withdrawal symptoms. Drug Alcohol Depend. 2007;86(1):22 " пїЅ29.
  • Denis пїЅ пїЅC, Lavie пїЅ пїЅE, Fatseas пїЅ пїЅM, et al. Psychotherapeutic interventions for cannabis abuse and/or dependence in outpatient settings. Cochrane Database Syst Rev. 2006;(3):CD005336.
  • Fergusson пїЅ пїЅDM, Boden пїЅ пїЅJM. Cannabis use and later life outcomes. Addiction. 2008;103(6):969 " пїЅ976.
  • Freeman пїЅ пїЅMJ, Rose пїЅ пїЅDZ, Myers пїЅ пїЅMA, et al. Ischemic stroke after use of the synthetic marijuana "spice. " пїЅ Neurology. 2013;81(24):2090 " пїЅ2093.
  • Hooper пїЅ пїЅSR, Woolley пїЅ пїЅD, De Bellis пїЅ пїЅMD. Intellectual, neurocognitive, and academic achievement in abstinent adolescents with cannabis use disorder. Psychopharmacology (Berl). 2014;231(8):1467 " пїЅ1477.
  • Hubbard пїЅ пїЅJR, Franco пїЅ пїЅSE, Onaivi пїЅ пїЅES. Marijuana: medical implications. Am Fam Physician. 1999;60(9):2583 " пїЅ2593.
  • National Institute on Drug Abuse. Research Report Series: Marijuana Abuse. Bethesda, MD: U.S. Department of Health and Human Services and National Institute of Health; 2010.
  • Vandrey пїЅ пїЅR, Haney пїЅ пїЅM. Pharmacotherapy for cannabis dependence: how close are we? CNS Drugs. 2009;23(7):543 " пїЅ553.
  • Winstock пїЅ пїЅAR, Ford пїЅ пїЅC, Witton пїЅ пїЅJ. Assessment and management of cannabis use disorders in primary care. BMJ. 2010;340:c1571.

CODES

ICD10

  • F12.10 Cannabis abuse, uncomplicated
  • F12.20 Cannabis dependence, uncomplicated
  • F12.288 Cannabis dependence with other cannabis-induced disorder
  • F12.159 Cannabis abuse with psychotic disorder, unspecified

ICD9

  • 305.20 Cannabis abuse, unspecified
  • 304.30 Cannabis dependence, unspecified

SNOMED

  • 37344009 Cannabis abuse
  • 85005007 Cannabis dependence (disorder)
  • 703848005 Cannabis withdrawal (disorder)
  • 77355000 Cannabis-induced organic mental disorder (disorder)

CLINICAL PEARLS

  • Marijuana abuse may result in poor performance in school or work, legal problems, and arguments with family.
  • Patients with schizophrenia are frequently found to be using marijuana and their use hindering the treatment for schizophrenia. Management of these dual diagnoses is important for the successful treatment of schizophrenia.
  • Patients should be screened for marijuana use and asked about frequency and amount used.
  • Effects of smoked marijuana can last 1 to 3 hours. Effects from foods or beverages containing marijuana appear later, usually in 30 minutes to 1 hour but can last up to 4 hours.
  • Smoking marijuana delivers significantly more THC into the bloodstream than eating or drinking the drug.
  • Acute marijuana intoxication is manifested by conjunctival injection, increased heart rate, euphoria, heightened sensory perception, altered perception of time, increased appetite, poor short-term memory and concentration, and fatigue. Large doses may result in acute psychosis, delusions, or hallucinations.
  • Inquire all patients about their use of marijuana. Changes in values and attitudes have made marijuana use more mainstream, and patients do not consider marijuana a substance of abuse.
  • Withdrawal symptoms include nausea, weight loss, decreased appetite, insomnia, and depressed mood. Peaks on day 2 or 3 and most are over by day 7.
  • Cognitive-behavioral therapy, motivational interviewing, motivational enhancement therapy, and contingency management are four methods of behavioral-based interventions used in the treatment of marijuana abuse.
  • Some recent research finds that adolescents with cannabis use disorder may not be susceptible to THC neuropsychological deficits once they achieve remission from all drugs for at least 30 days.