Is your patient’s cannabis use problematic?

,; ,; ,

doi:10.12788/jfp.0083

Applied Evidence

Is your patient’s cannabis use problematic?

J Fam Pract. 2020 October;69(8):379-385 | 10.12788/jfp.0083

PDF Download

References

1. Sarvet AL, Wall MM, Keyes KM, et al. Recent rapid decrease in adolescents’ perception that marijuana is harmful, but no concurrent increase in use. Drug Alcohol Depend. 2018;186:68-74.

2. Compton WM, Han B, Jones CM, Blanco C, Hughes A. Marijuana use and use disorders in adults in the USA, 2002-14: analysis of annual cross-sectional surveys. Lancet Psychiatry. 2016;3:954-964.

3. Lapham GT, Lee AK, Caldeiro RM, et al. Frequency of cannabis use among primary care patients in Washington state. J Am Board Fam Med. 2017;30:795‐805.

4. Chandra S, Radwan MM, Majumdar CG, et al. New trends in cannabis potency in USA and Europe during the last decade (2008-2017). Eur Arch Psychiatry Clin Neurosci. 2019;269:5-15.

5. Sevigny EL, Pacula RL, Heaton P. The effects of medical marijuana laws on potency. Int J Drug Policy. 2014;25:308-319.

6. Monte AA, Shelton SK, Mills E, et al. Acute illness associated with cannabis use, by route of exposure: an observational study. Ann Intern Med. 2019;170:531-537.

7. Scott JC, Slomiak ST, Jones JD, et al. Association of cannabis with cognitive functioning in adolescents and young adults: a systematic review and meta-analysis. JAMA Psychiatry. 2018;75:585-595.

8. Gruber SA, Sagar KA, Dahlgren MK, et al. Age of onset of marijuana use and executive function. Psychol Addict Behav. 2012;26:496-506.

9. 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-E2664.

10. Mammen G, Rueda S, Roerecke M, et al. Association of cannabis with long-term clinical symptoms in anxiety and mood disorders: a systematic review of prospective studies. J Clin Psychiatry. 2018;79:17r11839.

11. Gage SH, Hickman M, Zammit S. Association between cannabis and psychosis: epidemiologic evidence. Biol Psychiatry. 2016;79:549-556.

12. Singh A, Saluja S, Kumar A, et al. Cardiovascular complications of marijuana and related substances: a review. Cardiol Ther. 2018;7:45-59.

13. Volkow ND, Compton WM, Weiss SR. Adverse health effects of marijuana use. N Engl J Med. 2014;370:2219-2227.

14. Bari M, Battista N, Pirazzi V, et al. The manifold actions of endocannabinoids on female and male reproductive events. Front Biosci (Landmark Ed). 2011;16:498-516.

15. Hayatbakhsh MR, Flenady VJ, Gibbons KS, et al. Birth outcomes associated with cannabis use before and during pregnancy. Pediatr Res. 2012;71:215-219.

16. Saurel-Cubizolles M-J, Prunet C, Blondel B. Cannabis use during pregnancy in France in 2010. BJOG. 2014;121:971-977.

17. Prunet C, Delnord M, Saurel-Cubizolles M-J, et al. Risk factors of preterm birth in France in 2010 and changes since 1995: results from the French national perinatal surveys. J Gynecol Obstet Hum Reprod. 2017;46:19-28.

18. Kondrad EC, Reed AJ, Simpson MJ, et al. Lack of communication about medical marijuana use between doctors and their patients. J Am Board Fam Med. 2018;31:805-808.

19. Casajuana C, López-Pelayo H, Balcells MM, et al. Definitions of risky and problematic cannabis use: a systematic review. Subst Use Misuse. 2016;51:1760-1770.

20. Norberg MM, Gates P, Dillon P, et al. Screening and managing cannabis use: comparing GP’s and nurses’ knowledge, beliefs, and behavior. Subst Abuse Treat Prev Policy. 2012;7:31.

21. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington DC: APA Publishing; 2013:509-516.

22. Hasin DS, Saha TD, Kerridge BT, et al. Prevalence of marijuana use disorders in the United States between 2001-2002 and 2012-2013. JAMA Psychiatry. 2015;72:1235-1242.

23. Smith PC, Schmidt SM, Allensworth-Davies D, et al. A single-question screening test for drug use in primary care. Arch Intern Med. 2010;170:1155-1160.

24. Fischer B, Jones W, Shuper P, et al. 12-month follow-up of an exploratory ‘brief intervention’ for high-frequency cannabis users among Canadian university students. Subst Abuse Treat Prev Policy. 2012;7:15.

25. Turner SD, Spithoff S, Kahan M. Approach to cannabis use disorder in primary care: focus on youth and other high-risk users. Can Fam Physician. 2014;60:801-808.

26. Smart R, Caulkins JP, Kilmer B, et al. Variation in cannabis potency & prices in a newly-legal market: evidence from 30 million cannabis sales in Washington State. Addiction. 2017;112:2167-2177.

27. Bonn-Miller MO, Loflin MJE, Thomas BF, et al. Labeling accuracy of cannabidiol extracts sold online. JAMA. 2017;318:1708-1709.

28. Richards JR, Bing ML, Moulin AK, et al. Cannabis use and acute coronary syndrome. Clin Toxicol (Phila). 2019;57:831-841.

29. Subramaniam VN, Menezes AR, DeSchutter A, et al. The cardiovascular effects of marijuana: are the potential adverse effects worth the high? Mo Med. 2019;116:146-153.

30. Jones RT. Cardiovascular system effects of marijuana. J Clin Pharmacol. 2002;42:58S-63S.

31. 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;167:221-228.

32. Bramness JG, von Soest T. A longitudinal study of cannabis use increasing the use of asthma medication in young Norwegian adults. BMC Pulm Med. 2019;19:52.

33. Moore BA, Augustson EM, Moser RP, et al. Respiratory effects of marijuana and tobacco use in a U.S. sample. J Gen Intern Med. 2005;20:33-37.

34. Tashkin DP. Does marijuana pose risks for chronic airflow obstruction? Ann Am Thorac Soc. 2015;12:235-236.

35. McGuire PK, Jones P, Harvey I, et al. Morbid risk of schizophrenia for relatives of patients with cannabis-associated psychosis. Schizophr Res. 1995;15:277-281.

36. Hall W, Degenhardt L. Cannabis use and the risk of developing a psychotic disorder. World Psychiatry. 2008;7:68-71.

37. Gerlach J, Koret B, Gereš N, et al. Clinical challenges in patients with first episode psychosis and cannabis use: mini-review and a case study. Psychiatr Danub. 2019;31(suppl 2):162-170.

38. Patel R, Wilson R, Jackson R, et al. Association of cannabis use with hospital admission and antipsychotic treatment failure in first episode psychosis: an observational study. BMJ Open. 2016;6:e009888.

39. Day NL, Richardson GA, Goldschmidt L, et al. Effect of prenatal marijuana exposure on the cognitive development of offspring at age three. Neurotoxicol Teratol. 1994;16:169-175.

40. Goldschmidt L, Day NL, Richardson GA. Effects of prenatal marijuana exposure on child behavior problems at age 10. Neurotoxicol Teratol. 2000;22:325-336.

41. Corsi DJ, Walsh L, Weiss D, et al. Association between self-reported prenatal cannabis use and maternal, perinatal, and neonatal outcomes. JAMA. 2019;322:145-152.

42. Baker T, Datta P, Rewers-Felkins K, et al. Transfer of inhaled cannabis into human breast milk. Obstet Gynecol. 2018;131:783-788.

43. Thompson K, Leadbeater B, Ames M, et al. Associations between marijuana use trajectories and educational and occupational success in young adulthood. Prev Sci. 2019;20:257-269.

44. Yuan M, Kanellopoulos T, Kotbi N. Cannabis use and psychiatric illness in the context of medical marijuana legalization: a clinical perspective. Gen Hosp Psychiatry. 2019;61:82-83.

45. Ronen A, Gershon P, Drobiner H, et al. Effects of THC on driving performance, physiological state and subjective feelings relative to alcohol. Accid Anal Prev. 2008;40:926-934.

46. Robbe H. Marijuana’s impairing effects on driving are moderate when taken alone but severe when combined with alcohol. Hum Psychopharmacol Clin Exp. 1998;13(suppl 2):S70-S78.

47. Lenné MG, Dietze PM, Triggs TJ, et al. The effects of cannabis and alcohol on simulated arterial driving: influences of driving experience and task demand. Accid Anal Prev. 2010;42:859-866.

48. Anderson BM, Rizzo M, Block RI, et al. Sex differences in the effects of marijuana on simulated driving performance. J Psychoactive Drugs. 2010;42:19-30.

49. Laumon B, Gadegbeku B, Martin J-L, Biecheler M-B. Cannabis intoxication and fatal road crashes in France: population based case-control study. BMJ. 2005;331:1371.

50. Asbridge M, Poulin C, Donato A. Motor vehicle collision risk and driving under the influence of cannabis: evidence from adolescents in Atlantic Canada. Accid Anal Prev. 2005;37:1025-1034.

51. Mann RE, Adlaf E, Zhao J, et al. Cannabis use and self-reported collisions in a representative sample of adult drivers. J Safety Res. 2007;38:669-674.

52. Taylor J, Wiens T, Peterson J, et al. Characteristics of e-cigarette, or vaping, products used by patients with associated lung injury and products seized by law enforcement—Minnesota, 2018 and 2019. MMWR Morb Mortal Wkly Rep. 2019;68:1096-1100.

53. Hancock-Allen JB, Barker L, VanDyke M, et al. Notes from the field: death following ingestion of an edible marijuana product—Colorado, March 2014. MMWR Morb Mortal Wkly Rep. 2015;64:771-772.

54. Murray RM, Quigley H, Quattrone D, et al. Traditional marijuana, high-potency cannabis and synthetic cannabinoids: increasing risk for psychosis. World Psychiatry. 2016;15:195-204.

55. Di Forti MD, Sallis H, Allegri F, et al. Daily use, especially of high-potency cannabis, drives the earlier onset of psychosis in cannabis users. Schizophr Bull. 2014;40:1509-1517.

56. Miller WR. Motivational interviewing: research, practice, and puzzles. Addict Behav. 1996;21:835-842.

57. Gates PJ, Sabioni P, Copeland J, et al. Psychosocial interventions for cannabis use disorder. Cochrane Database Syst Rev. 2016;(5):CD005336.

58. Wilkinson ST, Stefanovics E, Rosenheck RA. Marijuana use is associated with worse outcomes in symptom severity and violent behavior in patients with posttraumatic stress disorder. J Clin Psychiatry. 2015;76:1174-1180.

59. Cougle JR, Bonn-Miller MO, Vujanovic AA, et al. Posttraumatic stress disorder and cannabis use in a nationally representative sample. Psychol Addict Behav. 2011;25:554-558.

60. Johnson MJ, Pierce JD, Mavandadi S, et al. Mental health symptom severity in cannabis using and non-using veterans with probable PTSD. J Affect Disord. 2016;190:439-442.

61. Wilkinson ST, Radhakrishnan R, D’Souza DC. A systematic review of the evidence for medical marijuana in psychiatric indications. J Clin Psychiatry. 2016;77:1050-1064.

62. Black N, Stockings E, Campbell G, et al. Cannabinoids for the treatment of mental disorders and symptoms of mental disorders: a systematic review and meta-analysis. Lancet Psychiatry. 2019;6:995-1010.

63. Bonnet U, Preuss U. The cannabis withdrawal syndrome: current insights. Subst Abuse Rehabil. 2017;8:9-37.

64. Vandrey R, Smith MT, McCann UD, et al. Sleep disturbance and the effects of extended-release zolpidem during cannabis withdrawal. Drug Alcohol Depend. 2011;117:38-44.

65. 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;37:1689-1698.

66. Weinstein A, Miller H, Tal E, et al. Treatment of cannabis withdrawal syndrome using cognitive-behavioral therapy and relapse prevention for cannabis dependence. J Groups Addict Recover. 2010;5:240-263.

Abstain from cannabis with high THC content. High-potency cannabis (> 10% THC) is associated with earlier onset of first-episode psychosis.^54,55

Motivational interviewing

Motivational interviewing (MI) is a psychosocial approach that emphasizes a patient’s self-efficacy and an interviewer’s positive feedback to collaboratively address substance use.⁵⁶ MI can be performed in short, discrete sessions. Such interventions can reduce the average number of days of cannabis use. One large-scale Cochrane review found that cognitive behavioral therapy (CBT), motivational enhancement therapy, or the 2 therapies combined most consistently reduced the frequency of cannabis use reported by patients at early follow-up.⁵⁷

Address underlying conditions

Some patients use cannabis to self-medicate for pain, insomnia, nausea, and anxiety. Identify these conditions and address them with first-line pharmacologic or psychotherapeutic interventions when possible. This is especially important for conditions in which long-term cannabis use may adversely impact outcomes, such as in posttraumatic stress disorder, anxiety, and mood disorders.^58-60 Little evidence exists for the use of cannabis as treatment of any primary psychiatric disorder.^61,62 Family physicians who are uncomfortable treating a specific underlying condition can consult specialists in pain management, sleep medicine, psychiatry, and neurology.

Mitigate withdrawal symptoms

Discontinuation of cannabis use may lead to withdrawal symptoms such as waxing and waning irritability, restlessness, sweating, aggression, anxiety, depressed mood, sleep disturbance, or changes in appetite.^63,64 These symptoms typically emerge within the first couple days of abstinence and can last up to 28 days.^63,64 Although the US Food and Drug Administration has not approved any medications for CUD treatment, and there are no established protocols for detoxification, there is evidence that CBT or medications such as gabapentin or zolpidem can reduce the intensity of withdrawal symptoms.^65,66

Refer to an addiction specialist

Consider referring patients with problematic cannabis use to an addiction specialist with expertise in psychopharmacologic and psychotherapeutic approaches to managing substance use.

Continue to: CASE