Cannabis use disorder: Treatment, prognosis, and long-term medical effects
- Scott A Teitelbaum, MD
Scott A Teitelbaum, MD
- Professor of Psychiatry
- University of Florida
- Robert L DuPont, MD
Robert L DuPont, MD
- Clinical Professor of Psychiatry
- Georgetown University School of Medicine
- John A Bailey, MD
John A Bailey, MD
- Clinical Assistant Professor of Psychiatry
- University of Florida
Cannabis is the most commonly used illegal substance worldwide . Approximately 160 million people or approximately four percent of the world’s population between the ages of 15 and 64 years have been estimated to have used cannabis at least once in the past year.
The psychoactive properties of cannabis are primarily due to delta-9-tetrahydrocannabinol (THC) . The THC content of cannabis has increased significantly since the late 1960s from approximately 1 to 5 percent to as much as 10 to 15 percent . This increased potency may contribute to increased rates of cannabis use disorder.
The psychiatric diagnoses, cannabis abuse and cannabis dependence, in DSM-IV-TR were replaced by one diagnosis, cannabis use disorder, in DSM-5 . Although the crosswalk between DSM-IV and DSM-5 disorders is imprecise, cannabis dependence is approximately comparable to cannabis use disorder, moderate to severe subtype, while cannabis abuse is similar to the mild subtype.
The prognosis, treatment, and long-term medical effects of cannabis use disorder are reviewed here. Other issues related to cannabis use disorder are discussed separately. Treatment of medical conditions such as chemotherapy-induced emesis and cancer pain with cannabinoids are discussed separately. Other issues related to cannabis intoxication or addiction are discussed separately. (See "Cannabis use disorder: Clinical features and diagnosis" and "Characteristics of antiemetic drugs", section on 'Cannabinoids' and "Cancer pain management: Adjuvant analgesics (coanalgesics)", section on 'Cannabis and cannabinoids' and "Cannabis use disorder: Epidemiology, comorbidity, and pathogenesis" and "Cannabis (marijuana): Acute intoxication", section on 'Management'.)
TREATMENT PRINCIPLES AND OVERVIEW
Treatment for cannabis use disorder usually occurs on an outpatient basis, but residential treatment may be required for patients who cannot remain abstinent in an ambulatory setting or those with multiple concurrent substance use disorders. Treatment may occur in a partial hospital or inpatient setting if the patient is psychotic, suicidal, or agitated, or has been hospitalized for another psychiatric disorder.
- Leggett T, United Nations Office on Drugs and Crime. A review of the world cannabis situation. Bull Narc 2006; 58:1.
- Ashton CH. Pharmacology and effects of cannabis: a brief review. Br J Psychiatry 2001; 178:101.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, American Psychiatric Association, Washington DC 2000.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington, VA 2013.
- American Psychiatric Association. Practice guideline for the treatment of patients with substance use disorders, second edition. Am J Psychiatry 2007; 164(Suppl):1.
- Moore BA, Budney AJ. Abstinence at intake for marijuana dependence treatment predicts response. Drug Alcohol Depend 2002; 67:249.
- Denis C, Lavie E, Fatséas M, Auriacombe M. Psychotherapeutic interventions for cannabis abuse and/or dependence in outpatient settings. Cochrane Database Syst Rev 2006; :CD005336.
- Nordstrom BR, Levin FR. Treatment of cannabis use disorders: a review of the literature. Am J Addict 2007; 16:331.
- Gray KM, Carpenter MJ, Baker NL, et al. A double-blind randomized controlled trial of N-acetylcysteine in cannabis-dependent adolescents. Am J Psychiatry 2012; 169:805.
- Cooper, ZD. Cannabis reinforcement and dependence: role of the cannabinoid CB1 receptor. Addict Biology 2008: 13:188.
- Dutra L, Stathopoulou G, Basden SL, et al. A meta-analytic review of psychosocial interventions for substance use disorders. Am J Psychiatry 2008; 165:179.
- Elkashef A, Vocci F, Huestis M, et al. Marijuana neurobiology and treatment. Subst Abus 2008; 29:17.
- DiClemente, Garay, M, Gemmell, L. Motivational enhancement. In: The American Psychiatric Publishing Textbook of Substance Abuse Treatment, 4th ed, Galanter, M, Kleber HD (Ed), American Psychiatric Publishing, Washington, DC 2008. p.366.
- Marijuana Treatment Project Research Group. Brief treatments for cannabis dependence: findings from a randomized multisite trial. J Consult Clin Psychol 2004; 72:455.
- Dennis M, Godley SH, Diamond G, et al. The Cannabis Youth Treatment (CYT) Study: main findings from two randomized trials. J Subst Abuse Treat 2004; 27:197.
- Lichtman AH, Martin BR. Cannabinoid tolerance and dependence. Handb Exp Pharmacol 2005; :691.
- Carpenter KM, McDowell D, Brooks DJ, et al. A preliminary trial: double-blind comparison of nefazodone, bupropion-SR, and placebo in the treatment of cannabis dependence. Am J Addict 2009; 18:53.
- 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; 37:1689.
- Haney M, Hart CL, Vosburg SK, et al. Marijuana withdrawal in humans: effects of oral THC or divalproex. Neuropsychopharmacology 2004; 29:158.
- Levin FR, McDowell D, Evans SM, et al. Pharmacotherapy for marijuana dependence: a double-blind, placebo-controlled pilot study of divalproex sodium. Am J Addict 2004; 13:21.
- Budney AJ, Vandrey RG, Hughes JR, et al. Oral delta-9-tetrahydrocannabinol suppresses cannabis withdrawal symptoms. Drug Alcohol Depend 2007; 86:22.
- Haney M, Hart CL, Vosburg SK, et al. Effects of THC and lofexidine in a human laboratory model of marijuana withdrawal and relapse. Psychopharmacology (Berl) 2008; 197:157.
- Levin FR, Kleber HD. Use of dronabinol for cannabis dependence: two case reports and review. Am J Addict 2008; 17:161.
- Perkonigg A, Goodwin RD, Fiedler A, et al. The natural course of cannabis use, abuse and dependence during the first decades of life. Addiction 2008; 103:439.
- von Sydow K, Lieb R, Pfister H, et al. The natural course of cannabis use, abuse and dependence over four years: a longitudinal community study of adolescents and young adults. Drug Alcohol Depend 2001; 64:347.
- Swift W, Hall W, Copeland J. One year follow-up of cannabis dependence among long-term users in Sydney, Australia. Drug Alcohol Depend 2000; 59:309.
- Mennes CE, Ben Abdallah A, Cottler LB. The reliability of self-reported cannabis abuse, dependence and withdrawal symptoms: multisite study of differences between general population and treatment groups. Addict Behav 2009; 34:223.
- Moore BA, Budney AJ. Relapse in outpatient treatment for marijuana dependence. J Subst Abuse Treat 2003; 25:85.
- Fergusson DM, Horwood LJ, Swain-Campbell N. Cannabis use and psychosocial adjustment in adolescence and young adulthood. Addiction 2002; 97:1123.
- Eisen SA, Chantarujikapong S, Xian H, et al. Does marijuana use have residual adverse effects on self-reported health measures, socio-demographics and quality of life? A monozygotic co-twin control study in men. Addiction 2002; 97:1137.
- Tetrault JM, Crothers K, Moore BA, et al. Effects of marijuana smoking on pulmonary function and respiratory complications: a systematic review. Arch Intern Med 2007; 167:221.
- Wu TC, Tashkin DP, Djahed B, Rose JE. Pulmonary hazards of smoking marijuana as compared with tobacco. N Engl J Med 1988; 318:347.
- Moore BA, Augustson EM, Moser RP, Budney AJ. Respiratory effects of marijuana and tobacco use in a U.S. sample. J Gen Intern Med 2005; 20:33.
- Pletcher MJ, Vittinghoff E, Kalhan R, et al. Association between marijuana exposure and pulmonary function over 20 years. JAMA 2012; 307:173.
- Hashibe M, Straif K, Tashkin DP, et al. Epidemiologic review of marijuana use and cancer risk. Alcohol 2005; 35:265.
- Mehra R, Moore BA, Crothers K, et al. The association between marijuana smoking and lung cancer: a systematic review. Arch Intern Med 2006; 166:1359.
- Sridhar KS, Raub WA Jr, Weatherby NL, et al. Possible role of marijuana smoking as a carcinogen in the development of lung cancer at a young age. J Psychoactive Drugs 1994; 26:285.
- Berthiller J, Lee YC, Boffetta P, et al. Marijuana smoking and the risk of head and neck cancer: pooled analysis in the INHANCE consortium. Cancer Epidemiol Biomarkers Prev 2009; 18:1544.
- Chacko JA, Heiner JG, Siu W, et al. Association between marijuana use and transitional cell carcinoma. Urology 2006; 67:100.
- Grant I, Gonzalez R, Carey CL, et al. Non-acute (residual) neurocognitive effects of cannabis use: a meta-analytic study. J Int Neuropsychol Soc 2003; 9:679.
- Lyketsos CG, Garrett E, Liang KY, Anthony JC. Cannabis use and cognitive decline in persons under 65 years of age. Am J Epidemiol 1999; 149:794.
- Lyons MJ, Bar JL, Panizzon MS, et al. Neuropsychological consequences of regular marijuana use: a twin study. Psychol Med 2004; 34:1239.
- Meier MH, Caspi A, Ambler A, et al. Persistent cannabis users show neuropsychological decline from childhood to midlife. Proc Natl Acad Sci U S A 2012; 109:E2657.
- Solowij N, Stephens RS, Roffman RA, et al. Cognitive functioning of long-term heavy cannabis users seeking treatment. JAMA 2002; 287:1123.
- Bolla KI, Brown K, Eldreth D, et al. Dose-related neurocognitive effects of marijuana use. Neurology 2002; 59:1337.
- Pope HG Jr, Gruber AJ, Hudson JI, et al. Early-onset cannabis use and cognitive deficits: what is the nature of the association? Drug Alcohol Depend 2003; 69:303.
- Yap MB, Whittle S, Yücel M, et al. Interaction of parenting experiences and brain structure in the prediction of depressive symptoms in adolescents. Arch Gen Psychiatry 2008; 65:1377.
- Bolla KI, Eldreth DA, Matochik JA, Cadet JL. Neural substrates of faulty decision-making in abstinent marijuana users. Neuroimage 2005; 26:480.
- Herning RI, Better WE, Tate K, Cadet JL. Cerebrovascular perfusion in marijuana users during a month of monitored abstinence. Neurology 2005; 64:488.
- Adams IB, Martin BR. Cannabis: pharmacology and toxicology in animals and humans. Addiction 1996; 91:1585.
- Large M, Sharma S, Compton MT, et al. Cannabis use and earlier onset of psychosis: a systematic meta-analysis. Arch Gen Psychiatry 2011; 68:555.
- Moore TH, Zammit S, Lingford-Hughes A, et al. Cannabis use and risk of psychotic or affective mental health outcomes: a systematic review. Lancet 2007; 370:319.
- Fergusson DM, Poulton R, Smith PF, Boden JM. Cannabis and psychosis. BMJ 2006; 332:172.
- Caspi A, Moffitt TE, Cannon M, et al. Moderation of the effect of adolescent-onset cannabis use on adult psychosis by a functional polymorphism in the catechol-O-methyltransferase gene: longitudinal evidence of a gene X environment interaction. Biol Psychiatry 2005; 57:1117.
- Henquet C, Rosa A, Delespaul P, et al. COMT ValMet moderation of cannabis-induced psychosis: a momentary assessment study of 'switching on' hallucinations in the flow of daily life. Acta Psychiatr Scand 2009; 119:156.
- Zammit S, Moore TH, Lingford-Hughes A, et al. Effects of cannabis use on outcomes of psychotic disorders: systematic review. Br J Psychiatry 2008; 193:357.
- Lynskey MT, Glowinski AL, Todorov AA, et al. Major depressive disorder, suicidal ideation, and suicide attempt in twins discordant for cannabis dependence and early-onset cannabis use. Arch Gen Psychiatry 2004; 61:1026.
- Ghuran A, Nolan J. Recreational drug misuse: issues for the cardiologist. Heart 2000; 83:627.
- Jones RT. Cardiovascular system effects of marijuana. J Clin Pharmacol 2002; 42:58S.
- Mittleman MA, Lewis RA, Maclure M, et al. Triggering myocardial infarction by marijuana. Circulation 2001; 103:2805.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, text revision, 4th ed, American Psychiatric Association, Washington 2000.
- Sullivan S. Cannabinoid hyperemesis. Can J Gastroenterol 2010; 24:284.
- Kolodny RC, Masters WH, Kolodner RM, Toro G. Depression of plasma testosterone levels after chronic intensive marihuana use. N Engl J Med 1974; 290:872.
- Hembree, WC, Nahas, GG, Zeidenberg, P, et al. Changes in human spermatozoa associated with high-dose marijuana smoking. In: Nahas, GG (ed) Marijuana and Medicine, Humana Press, Totowa, NJ, 2001.
- Cohen, S. Marijuana and reproductive functions. Drug Abuse and Alcoholism News 1985; 13:1.
- Thomson WM, Poulton R, Broadbent JM, et al. Cannabis smoking and periodontal disease among young adults. JAMA 2008; 299:525.
- Yazulla S. Endocannabinoids in the retina: from marijuana to neuroprotection. Prog Retin Eye Res 2008; 27:501.
- TREATMENT PRINCIPLES AND OVERVIEW
- PSYCHOSOCIAL INTERVENTIONS
- Cognitive behavioral therapy
- Motivational interviewing
- Voucher based incentives
- Peer support groups
- Family therapy
- Cannabinoid agonists
- COURSE AND PROGNOSIS
- Psychosocial functioning and health
- - Short-term outcomes
- - Long-term outcomes
- LONG TERM MEDICAL EFFECTS OF CANNABIS USE
- Neuropsychological effects
- - Psychotic disorders
- - Depression
- Immune system
- Cannabinoid hyperemesis syndrome
- Ophthalmologic effects
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS