Brigham and Women’s Hospital, Boston, MA (Drs. Hsu and Shah); Beth Israel Deaconess Medical Center and Harvard Medical School, Boston (Dr. Hill) mhsu7@partners.org
The authors reported no potential conflict of interest relevant to this article.
Individuals who do not meet DSM-5 criteria for cannabis use disorder may still have problematic use. The screening tool and 5 interventions detailed here can help.
› Address underlying conditions for which patients use recreational cannabis to manage symptoms. B
› Consider discrete, in-office sessions of motivational interviewing and referral for cognitive behavioral therapy for patients with problematic cannabis use. B
› Provide counseling around harm reduction for all patients—especially those with problematic cannabis use. C
› Consider referral to an addiction specialist for patients with cannabis use disorder or other problematic cannabis use. C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence B Inconsistent or limited-quality patient-oriented evidence C Consensus, usual practice, opinion, disease-oriented evidence, case series
References
CASE
Jessica F is a new 23-year-old patient at your clinic who is seeing you to discuss her severe anxiety. She also has asthma and reports during your exploration of her family history that her father has been diagnosed with schizophrenia. She has been using 3 cartridges of cannabis vape daily to help “calm her mind” but has never tried other psychotropic medications and has never been referred to a psychiatrist.
How would you proceed with this patient?
Despite emerging evidence of the harmful effects of cannabis consumption, public perception of harm has steadily declined over the past 10 years.1,2 More adults are using cannabis than before and using it more frequently. Among primary care patients who consume cannabis recreationally, about half report less than monthly consumption; 15% use it weekly, and 20% daily.3 The potency of cannabis products has also increased. In the past 2 decades, the average tetrahydrocannabinol (THC) content of recreational cannabis rose from 3% to 19%, and high-THC content delivery modalities such as vaporizer pens (“vapes”) were introduced.4,5
Health hazards of cannabis use include gastrointestinal dysfunction (eg, cannabinoid hyperemesis syndrome), acute psychosis or exacerbation of an existing mood, anxiety, or psychotic disorder, and cardiovascular sequelae such as myocardial infarction or dysrhythmia.6 Potential long-term effects include neurocognitive impairment among adolescents who use cannabis,7-9 worse outcomes in anxiety and mood disorders,10 schizophrenia,11 cardiovascular sequelae,12 chronic bronchitis,13 negative impact on reproductive function,14 and poor birth outcomes.15-17
Hidden in plain sight. Many patients who use cannabis report that their primary care physicians are unaware of their cannabis consumption.18 Inadequate screening for cannabis can be attributed to time constraints, inconsistent definitions for problematic or risky cannabis use, and lack of guidance.19,20 This article offers a more inclusive definition of “problematic cannabis use,” presents an up-to-date framework for evaluating it in the outpatient setting, and outlines potential interventions.
Your patient doesn’t meetthe DSM criteria, but …
Although it is important to identify cannabis use disorder (CUD) as defined in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5; TABLE 121,22), consider also the immediate and long-term consequences of cannabis use for individuals who do not meet criteria for CUD. “Problematic cannabis use,” as we define it, may also involve (a) high-risk behaviors or (b) contraindicating medical or psychiatric comorbidities (TABLE 26-9).
CASE
The patient in our case exhibited 4 factors indicative of problematic cannabis use: heavy vape use, cannabis use more than twice a week, asthma, and a family history of schizophrenia.
Continue to: Guidelines for screening and evaluation
